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Rev. 10/2018 1

Adult History Form

Patient's name: Frank Sample; age 34; Caucasian

How did you get here today? Bus/Taxi/Walked/Drove Myself/Driven by Fiancée (son’s mother)

Person completing form (relationship to the patient):

Self/Mother/Father/Son/Daughter/Interpreter/Spouse

Problems

Check any mental or emotional problems which you have:

_____ Learning problems (needed special classes in school, learning

disabilities, slow learner, brain damage)

X Depression (often feeling very sad)

_____ Anxiety (often feeling very nervous)

_____ Hallucinations (hearing voices or seeing things that others don't

X Trouble concentrating

_____ Can't get along with other people

_____ Violent behavior

_____ Drink too much alcohol

X Use illicit drugs (marijuana, heroin, cocaine, etc.)

_____ Memory problems

_____ Other: ______________________________________________

Check any problems below that apply to you: ___ Autism ___ Seizure Disorder ___ Mental Retardation ___ Bipolar (Manic Depressive)

___ Speech Problems ___ Schizophrenia ___ Brain Tumor ___ Stroke

___ Heart Attack ___ Brain injury ___ Lost consciousness ___ War or violent crime experience

Family History:

Marital Status: Married / Divorced / Never Married / Widowed

How many times have you been married? One time

How many children do you have? One Children's ages? 17 month old son; daughter died at 55 days old.

Whom do you live with? Currently live alone.

If divorced, when (your age or the year)? Will be final in one month.

If widowed, when? _________________

Check any statement that applies:

_____ My father died when I was _____

_____ My mother died when I was _____

X My parents separated or divorced when I was 4 or 5 years old.

_____ I was raised by both parents.

Where do you live? House/Apartment/Group Home/Hotel/Homeless/Other

Where were you born? City Carson Country __________

If you were born outside the USA, when did you come to this country? Always lived in Southern California.

Rev. 10/2018 2

Educational History

Circle the last grade you completed: 1 2 3 4 5 6 7 8 9 10 11 12

Educational degrees: HS Grad/GED/Assoc./Bach./Masters/Doct.

College (number of years): _____

Were you in special education classes? Yes No

What was your grade average in high school? A B C D F

What language do you speak best? Only English.

Vocational History

What types of work have you done (i.e., labor, cashiering, gardening, teaching,

construction, etc.): Welding, security, hanging glass

What was the longest time you stayed at a job? 2 years

What did you do on your last job? Iron worker apprentice

When did you last work? 5 years ago

Why did your last job end? Fell 30 feet, injured knee

Medical History:

List any medical (not psychiatric or behavioral) problems which you have been

diagnosed with: Severe migraines, pinched nerve in back.

List all medications which you currently take:

Medication Dose (m.g.) Times per day For what problem? None currently

Have you ever had surgery? List your age when you had surgery and the reason

below. Age 28: Reconstructive shoulder surgery.

Age 29: Reconstructive knee surgery (work injury).

Have you ever been hospitalized overnight for medical reasons other than surgery? List

your age when you were hospitalized and the reason.

Age: Reason: None

Have you ever had a head injury that caused you to lose consciousness? Yes No

If so, how old were you? ________ How long were you unconscious? ________

Rev. 10/2018 3

Mental Health History:

Have you ever been placed in a psychiatric hospital? List your age when you were

hospitalized and the reason.

Age: Reason: None

Have you ever seen a counselor, psychologist, or psychiatrist? Yes

Age when you

attended Sessions

How long did you

attend?

Reason you

attended?

Type of therapist

(PhD, MD, School) 23 A few months while

incarcerated

“To get drugs to get

high.”

Psychiatrist

Has a doctor ever prescribed medication to you to help with depression, anxiety,

behavior, or mental problems (such as Ritalin, antidepressants, etc.)

Age when medication was

prescribed?

To help with what problem? Type of medication?

23 While in prison Haldol, Mellaril, Sinequan

Did you ever attempt suicide? Yes No

If yes, how many times? _____

When was the first time? __________

When was the last time? ___________

How did you try to do it? __________________________________

Legal problems

How many times have you been arrested or charged with a crime?

Never 1 2 3 4 5 or more

If yes, what crimes have you been charged with? Mostly drug related charges. Age 23-29, served 5½ years in prison for child endangerment regarding daughter’s death.

How old were you the first time you were in trouble with the law? 18 years old

When were you last charged with a crime? Might have current warrant – drug counseling not completed.

Have you ever been in jail or prison? Yes No

Rev. 10/2018 4

Alcohol and Drugs

How often do you drink alcohol?

Every day/Few times a week/Few times a month/Once a month or less/Never

Has drinking alcohol ever caused problems for you (other people tell you to drink less,

legal problems, relationship problems)? Yes No

If yes, at what age did alcohol start to cause problems? 12-13 years old

When did you have your last drink? Yesterday. Has a history of heavy drinking. Attended AA in prison & a few months after release.

Have you ever used illicit drugs? Yes No

If yes, which ones? Marijuana Cocaine PCP Heroin LSD

Amphetamines Barbituates Sniff glue/paint

Other _______________

When did you last use a drug? 1 month ago, used methamphetamines.

How old were you when you first used a drug? 14 years old.

Daily Functioning

Driving: Check the one which applies:

_____ I have never driven a car

_____ I still drive

X I used to drive a car but haven't since: 1 year ago, license revoked due to DUI.

Are you able to shower, bathe, and groom yourself without help? Yes No

Are you able to get dressed by yourself? Yes No

Are you able to pay bills, and keep track of money without help from other people?

Yes No

Describe what you do in a typical day: Talk to my son’s mother on the phone. Build scale models. I have periods when I scream & throw

things.

Rev. 10/2018 5

Mental Status Exam Patient’s Name: Frank Sample

General Appearance: Adeq. Gait Adeq Grooming Adeq Hygiene Casually & appropriately Dress

Older/Younger/Same as State Age

Attitude & General Behavior: √ Pleasant √ Cooperative ___ Oppositional

___ Perfunctory ___ Irritable √ Tries hardest √ Follows instructions

___ Does not initiate conversation ___ Guarded ___ Limited verbalization

___ Impulsive ___ Distractible ___Talkative ___ Agitated

Arrived 15 minutes late, called a few minutes before appt to say he would be late.

Sense of humor.

Mood & Affect √ Broad ___ Restricted ___ Blunted ___ Flat ___ Labile

___ Irritable ___ Tearful ___ Euthymic ___ Dysthymic ___ Elated ___ Anxious

Sleeping: “A little trouble” “How would you describe your mood?” “Up and down lately, real depressed

at times.”

Eating: Good Feel depressed a few times a month. 4-5 day period. First episode, age 15-16.

Stream of mental activity: Coherent Relevant Loose Assoc. Tangential Circumstantial

Poverty of speech Rate of speech: Slowed Normal Rapid Pressured Speech

Content: Delusions Preoccupations ___________________________________

Clear Distorted Slurred 100% intelligible

Sensorium & Orientation: Alert Aware of surroundings Confused Sedated Autistic Psychotic

Orientation: Date:_√ Day of week: √

City of exam: _________ City of residence: √

Memory: √ Age √ Birthdate √ Current president √ Last president

1 trials to reg. 3 objects, recall 3 out of 3 after 5 minutes

Digit span: 8 Forward, 4_Reverse

Fund of information: Above aver, WNL, mild/mod/sev deficient

# Legs on a dog ____ # ears _____ Where is your nose? _____

Days in wk _____ Days in yr _____ Sunrise √ Water boil temp. √

Concentration & Attention: Attn. to instructions: E G F P Task persistence: E G F P

Distractible Alphabet, Count 20-1: 8_ secs., _0 err.

Perceptual distortions: Hallucinations: None Visual Auditory

Frequency: _ Occurs during periods of deep depression, 2-3x per year.

Content: “Revenge”

Judgment & Insight: E G F P Neighbor’s house on fire: “Grab a hose & call 911”.

E G F P What makes it hard for you to work: “Depression”. Denies need for treatment, not committed to

substance abstinence.

Rev. 10/2018 6

During periods of Depression: [sad/tearful] [-decrease interest/pleasure] [sleep] [appetite]

[psychomotor] [fatigue] [worthless] [concentrate] [death thoughts]

Anxiety: [restless/keyed up] [fatigue] [concentration] [irritable] [tense] [sleep]

PTSD: [intrusive thts] [nightmares] [flashback] [reminders] [avoidance] [detached] [startle] ADHD: [careless mistakes] [don’t complete] [loses things] [distracted] [disorganized][fidgets] [out of seat] [noisy]

[talk too much] [won’t wait] [interrupts] [blurts out]

Autism: [-non-verbal] [-peer relat] [sharing interests] [lang delay][-conversation][stereotype-

repet lang][lack play][-restricted interests][inflex routines][stereotype-repet movement][part

preoccupation]

Mania: [elevated/irrit mood][grandiose][-sleep][talkative][racing

thoughts][distractible][+activity][risky beh]

Psychosis: [delusions][hallucinations][disorg speech][disorg/catatonic beh][flat

affect][avolitional]