BACKGROUND HISTORY QUESTIONNAIRE

Similar documents
PERSONAL HISTORY QUESTIONNAIRE

Atlanta Psychological Services

Beacon Assessment Center

DR. CESTNICK ADULT BACKGROUND QUESTIONNAIRE. Birth date: Age: Sex (circle one): Male Female. Home address: City: Zip Code:

Sofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005

MINDFUL WELLNESS CENTER, PLLC

COUNSELING ASSESSMENT REFERRAL AND BACKGROUND INFORMATION (Adult Form) cell telephones/fax #s/ addresses: (Spouse): (Emergency Contact):

DEVELOPMENTAL BEHAVIOURAL REFERRAL

Client Information Form

San Diego Center for the Treatment of Mood Disorders 1

ADULT PATIENT HISTORY FORM. Name: Address: City: State: Zip: Occupation (if applicable): Religious Affiliation (if applicable):

Child s Information (Please print) Name Birth Date Age Home Address City State Zip Code

Adult Information Form

Beacon Assessment Center Developmental Questionnaire Please complete prior to your first appointment

Adult Information Form Page 1

ADULT INITIAL EVALUATION: Patient Form

Do not write below this line DSM IV Code: Primary Secondary. Clinical Information

PHONE: RELATIONSHIP: ADDRESS:

Feil & Oppenheimer Psychological Services

Restore Counseling Center 630 E Southlake Blvd, Ste 127, Southlake, Tx

Sonja Benson, Ph.D., PLLC Licensed Psychologist

Christina Pucel Counseling 416 W. Main St Monongahela, PA /

JILL L. KOFENDER, PHD, PLLC. Licensed Clinical Psychologist ADULT CLIENT QUESTIONNAIRE. Client s Name Today s Date Gender Age Birthdate

Client s Name: Street City State Zip. Home Phone Work Phone Cell Phone. Student: Full-time Part-time Grade School. Current or past Education:

Psychiatric Nurse Practitioner Intake Form. General Information. 1. Name. 2. Date of Birth. 3. Age. 4. Gender. 5. Referred by

Anxiety Depression Sleep problems Thoughts of suicide. Panic Unusual thoughts Anger outbursts Changes in weight

CLIENT QUESTIONNAIRE. Preferred Name: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Relationship: Cell Phone:

Concussion Patient Self-Assessment: NEW

FMS Psychology, PLLC Adult Intake Form. Phone Number (Day): Phone Number (Evening):

1811 B Green Circle Valdosta, GA Do you have any problems at this time?

Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone:

NEUROPSYCHOLOGY APPOINTMENT CHECKLIST

Address: Spouse/Partner Name: Phone: Address:

CLIENT INFORMATION FORM. Name: Date: Address: Gender: City: State: Zip: Date of Birth: Social Security Number:

*IN10 BIOPSYCHOSOCIAL ASSESSMENT*

ADULT History Form (To be filled out by the person seeking treatment)

Please check all the behaviors and symptoms that you consider problematic:

Denise L. Newman, Ph.D.

Client Intake Form. Briefly describe the reason(s) you are seeking psychotherapy at this time:

REASON(S) FOR EVALUATION What concerns or difficulties led you to seek an evaluation now (or led someone to recommend one)?

Age Date of Birth Sex: Male Female. Ethnic or Racial Background Primary Language Secondary

APPLICATION FOR ADMISSION

MINOR CLIENT HISTORY

Name: Gender: male female Age: Date of birth: / / Preferred phone: cell home work other. Alternate phone: cell home work other.

Henrike B. Kroemer, Ph.D. ADULT HISTORY FORM

Francine Grevin, Psy.D. Licensed Clinical Psychologist PSY South Main Plaza, Suite 225 Telephone (925) CHILD HISTORY FORM

ADULT INTAKE FORM. Name

ADULT HISTORY QUESTIONNAIRE

Child/ Adolescent Questionnaire

CBT Intake Form. Patient Name: Preferred Name: Last. First. Best contact phone number: address: Address:

New Client Information. address: Date of Birth:

Lyris Bacchus Steuber, MS, LMFT MT Harley Lester Lane Apopka, FL Ph: , Fax:

Minor Intake Form. Child s Name DOB

Application and History for Adult

+ Monica Michael MA LPC LLC

S. W. ZIMOSTRAD, Ph.D. AND ASSOCIATES

ADULT QUESTIONNAIRE. What have you been told with regard to the problem?

Department of Psychiatry\Behavioral Health 200 Mercy Drive, Suite 201 Dubuque, IA or

PHARMACY INFORMATION:

PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT

Evergreen Behavioral Health Psychiatric Intake Form. Name: Date: Date of Birth:!

Name:, Sex:, Age: Ethnicity, Race. Date of Birth:, address: Address:, City: State:, County,, Zip: Telephone numbers: Home: ( ),Work: ( )

EMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION PART I: PERSONAL INFORMATION STREET ADDRESS CITY/STATE

Developmental-Behavioral Pediatrics Questionnaire for New Patients

Lisa Karabelnik, MD 68 South Main Street; Suite 200 West Hartford, CT P (860) F (860) Patient Name (Last, First, Middle)

CERTIFICATION AND AUTHORIZATION (if applicable)

Referral Form PERSONAL DETAILS. Reason for Referral: Please indicate clearly your reason for referral: CONTACT PERSONS Next of Kin 1: Name:

Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC

Baylor AT&T Memory Center 9101 N. Central Expressway, Suite 230 Dallas, Texas Phone: (214) Fax: (214)

EMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION. Important Information

Problem Summary. * 1. Name

Intake Questionnaire

Review Evaluation of Residuals of Traumatic Brain Injury (R-TBI) Disability Benefits Questionnaire * Internal VA or DoD Use Only*

Alcorn & Allison. clinical associates **C O N F I D E N T I A L**

Assessment Intake/History Form

To be completed by Patient. Client Questionnaire

Patient Questionnaire. Name: Date: A. What are the main concerns or problems that brought you here today?

New Patient Questionnaire

ADULT QUESTIONNAIRE. Date of Birth: Briefly describe the history and development of this issue from onset to present.

COLUMBUS PSYCHOLOGICAL ASSOCIATES, L.L.P.

New Patient Evaluation Form

Joan B. Jablow, APMHNP 45 Byram Lake Road Mt. Kisco, New York (914)

ADULT INTAKE/PSYCHOSOCIAL ASSESSMENT. Name: Date: Referred by:

LEXIE SMITH LPC 116 W. 7th, Suite 211 Stillwater, OK Date. Personal History Information

Intake Form. Presenting Problems and Concerns. When did it start and how does it affect you:

Demographic Information Form

COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:

HEALTH INFORMATION FORM

POST CONCUSSION SYMPTOM SCALE

NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:

SANDSTONE PSYCHOLOGICAL PRACTICE

Adult Service Application

Addictive Disorders Assessment Form

UCA Speech-Language Hearing Center UCA Box Donaghey Avenue Conway, AR Phone: Fax: APHASIA CASE HISTORY

LIFE INTEGRATION THERAPIES, PC., INC. KAY WHITEHEAD, MSW., LCSW., FT. 23 E.39 th St. INDIANAPOLIS, IN CLIENT HISTORY FORM

Name: Date: Who referred you? Current Psychiatrist: Clinical Information:

New Patient Information Form

Pain Interventions 30 Hagen Drive, Suite Culver Rd. Suite 2 Rochester, NY Rochester, NY (Voice) (Fax)

Mini Research Paper: Traumatic Brain Injury. Allison M McGee. Salt Lake Community College

Address: City/State/Zip: Home Phone: Cell: Pager: Work Phone: Employer/School: Emergency Contact: Phone:

Transcription:

BACKGROUND HISTORY QUESTIONNAIRE Name: Sex M F Address: Home Number: Work Number: Cell Number: Email: SSN: Name and Address of Employer: Date of Birth: Age: Ethnicity: Referred By: Referral Question or Presenting Problem: Primary Physician: Other Specialists (include name and specialty): MEDICAL HISTORY: Previous hospitalizations, surgeries or accidents (describe when occurred, age, length of stay): Serious illnesses: Medical problems currently affecting you: Family history of serious illnesses: Previous loss of consciousness related to head injury or concussion - If yes, describe circumstances, when occurred, medical treatment: History of seizures: Other neurological disorders (stroke, hemorrhage, etc.): Family history of neurological illness If yes, describe:

Current medications (name and dosage): Vision difficulties: Hearing difficulties: Previous tests performed: (please include year performed and results) EEG: Head CT scan: Brain MRI: Psychological Testing: Neuropsychological Testing: Other medical findings or diagnoses: PSYCHIATRIC HISTORY: History of emotional disorder/psychiatric treatment (diagnosis if known, age diagnosed, treating physician, medications prescribed): When did you first seek psychiatric treatment? For what problems did you seek treatment? Was treatment helpful? Current psychiatrist: (name, when treatment started, focus of treatment) Current medications prescribed (name, dosage): Medications taken in the past (name, dosage): Current therapist: (name, when treatment started, focus of treatment) Inpatient hospitalizations (hospital, age, nature and duration of treatment): Previous suicide attempts (age, injuries): Family history of psychiatric treatment or illness: 2

SUBSTANCE USE HISTORY: Previous/current use of: Nicotine (age began using, how long using, current usage): Alcohol (age began using, how long using, current usage): Ever experience blackouts or withdrawal symptoms? Recreational drugs (specify drug, age began using, how long using, current usage): Drug of choice, if any: Formal treatment for drug or alcohol abuse (detoxification, rehabilitation, AA or NA). If yes, describe: PERSONAL HISTORY: Place of Birth: Where Raised: Native Language: Handedness: Developmental milestones (e.g. walking, talking) attained early/late/within normal limits: Education including high school (include name of institution, degree obtained, year of graduation): School Problems (repeated grades, failed classes, special education, tutoring): If any, please describe: Ever diagnosed with a learning disability or Attention Deficit/Hyperactivity Disorder? If yes, when and by whom: Behavioral Problems as a child (if yes, describe): _ Current Occupation (include job title, company name): How long at current job? Last Job: Previous Work History: _ 3

Current Marital Status: S M D W If married, separated, divorced or widowed, please note when: List those individuals living with you (the patient) at the present time: Name Sex Age Relationship Education Occupation Health How long at current residence? List immediate family members not living with you (children, siblings, parents, etc.): Name Sex Age Relationship Education Occupation Health CURRENT COMPLAINTS Physical symptoms & changes: Weakness: Hearing defects: Numbness: Problems with taste: Muscle tics/twitches: Problems with smell: Clumsiness: Bladder/bowel control: Headache: Change in appetite/weight: Pain: Change in sleep pattern: Dizziness: Seizures: Nausea: Fainting spells: Visual defects: Other: Any Recent changes in: Appetite / Weight Sleep Energy levels Sexual interest / libido Behavioral concerns: Unusual fears: High activity level Slowed response: Sexual difficulties Destructiveness: Aggressiveness 4

Irritability: Restlessness Excessive sadness: Nightmares Self-destructive: Easily frustrated Stubbornness: Eating problems Sleep problems: Mood swings Suicidal thoughts Withdrawn Isolated Problems in driving: Intellectual Concerns: Difficulty planning or organizing Difficulty in completing activities Difficulty adapting to changes (rigid) Inability to concentrate Easily distracted Impulsive Difficulty learning or remembering Difficulty with comprehension Difficulty with expression Gets lost easily Difficulty with writing Difficulty with reading Difficulty with math Periods of confusion or disorientation Slowed thought processes Changes in mood or personality Change in the way you get along with others Change in social activities Are symptoms staying the same or getting worse? What is your best guess as to why the symptoms are happening? Has daily living at home, work or in social situations been affected by your symptoms? If yes, describe: What if anything, has helped your symptoms? 5

Please add any additional comments: 6

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback