Pinkston Psychology, LLC Ph. (318) Fx. (318) Completed this form Patient Spouse Parent Other

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Transcription:

Pinkston Psychology, LLC Ph. (318) 553-5099 paula@pinkstonpsychology.com Fx. (318) 553-5338 ADULT HISTORY FORM Date Completed this form Patient Spouse Parent Other Patient s Name Date of Birth Age Sex Race Marital Status Phone: Home Work Cell Briefly explain why you need this evaluation Injured while working (Workers Comp) No Yes Date Injured in accident No Yes Cause Date Involved in a lawsuit No Yes Explain Applying for Disability No Yes Granted Denied Date Do you have an attorney No Yes Attorney s Name Any thinking problems (attention or memory problems, etc.) No Yes When problems started Started Suddenly Slowly ; Got Better Worse Same Any changes in your Memory Speech Appearance Mood Movements Medical History Did your mother have any problems during her pregnancy with you Was your birth premature or were there complications Problems with your childhood development Please list current and past medical illnesses Age 09.09.17

2 of 5 Please list surgeries/hospitalizations Age Ever had Loss of consciousness / coma Explain Lead or other poisoning Explain Fever of 104 or above Explain Brain damage Explain Brain surgery Type Meningitis Explain Multiple sclerosis Parkinson s disease Cancer Type Diabetes Type High blood pressure Low blood pressure Headaches Explain Heart attack Sleeping problems Explain Sleep apnea Arthritis Explain Chronic pain Chronic fatigue Fibromyalgia Vision problems Cataract surgery Both Left Right Hearing problems Dizziness Tremors/shakiness Frequent falling Allergies Asthma Injured arms/hands/fingers Explain Other Head injury/concussion Age What happened Black Out No Yes How Long Remember the event No Yes Go to the hospital No Yes Treatment No Yes Last clear memory before injury First clear memory after injury Symptoms you had How long to recover Lasting problems

3 of 5 More than one head injury Age What happened Black Out No Yes How Long Remember the event No Yes Go to the hospital No Yes Treatment No Yes Last clear memory before injury First clear memory after injury Symptoms you had How long to recover Lasting problems Seizure Age first seizure Last seizure Describe Pass out during seizure No Partially Completely How long How long to recover after seizure Number of seizures per day, week, or month Mediations do you take for seizures Neuroimaging / testing EEG CT MRI PET/ SPECT Psychological Testing Date or Age Where Neuropsychological Testing Date or Age Where Current medications and reason for taking Medications taken in the past for 2 months or more Caffeine Use Drink or use caffeine (cola, coffee, tea, energy drinks) No Yes What kind and how much a day Tobacco Use Use tobacco No Yes How much per day How long have you used tobacco Did you use tobacco in the past No Yes How much When did you stop Why did you stop

4 of 5 Alcohol Use Do you drink alcohol No Yes How much per day For how long (since what age) Did you use alcohol in the past No Yes How much When did you stop Why did you stop Street drugs or medications used without a prescription Marijuana, Pot, Weed, Synthetic; LSD, Acid, PCP; Mushrooms, Ecstasy, MDMA Cocaine, Crack; Methamphetamine, Speed; Ritalin, Adderall, Diet Pills Lortab, OxyContin, Demerol, Vicodin, Codeine, Heroin, Morphine, Methadone Valium, Xanax, Klonopin, Ativan, Barbiturates, Benzodiazepine, Halcion Glue, Paint Thinner, Gasoline, Nitrous Oxide, Laughing Gas Other For each drug Name First time How often Last time Problems because of alcohol or drugs Relationship problems No Yes Explain Job problems Legal problems Treatment to stop using drugs or alcohol No Yes Place / Facility Date How long Mental Health Ever have really bad anxiety or depression, suicidal thoughts or feelings, or ever attempt suicide or hurt yourself on purpose No Yes Past or current psychological or psychiatric evaluation or treatment Type of Treatment Age Reason Social and Family History Served in the military No Yes Branch How long Highest Rank Type of Discharge Ever arrested No Yes Charges

5 of 5 Driver's license No Yes Drive now No Yes Hobbies, interests, activities Hand you write with Left-handed family members Family receive mental health treatment or hospitalized No Yes Parental Information Mother s education Job Medical/Psychiatric Problems Father s education Job Medical/Psychiatric Problems Educational History Graduated high school No Yes Explain Highest grade finished Grades GED No Yes When Repeat any grades No Yes Explain Special education No Yes Explain Any College No Yes Degree Major Years College Name Location Technical or Vocational Training No Yes Where Employment History Employed now No How long unemployed Reason Yes How long at your job Job title Please describe your past jobs Dates worked Job title Job duties Reason for leaving Who lives with you Name Age Relationship How you slept the night before this evaluation Anything else you would like us to know?

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