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Adult History Form

Patient's name: ______________________

How did you get here today? Bus / Taxi / Walked / Drove Myself /

Driven by _________________

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)

_____ Depression (often feeling very sad)

_____ Anxiety (often feeling very nervous)

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

_____ Can't get along with other people

_____ Violent behavior

_____ Drink too much alcohol

_____ 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? _____

How many children do you have? _____ Children's ages? ___

Whom do you live with? ___________________________________

If divorced, when (your age or the year)? ________________

If widowed, when? _________________

Check any statement that applies:

_____ My father died when I was _____

_____ My mother died when I was _____

_____ My parents separated or divorced when I was _____

_____ I was raised by both parents.

Where do you live? House/ApartmentGroup Home/Hotel/Homeless/Other

Where were you born? City __________ Country __________

If you were born outside the USA, when did you come to this country? _________

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? _____________________

Vocational History

What types of work have you done (i.e., labor, cashiering, gardening, teaching, construction, etc.): ___________________________________________________

What was the longest time you stayed at a job? ___________

What did you do on your last job? ________________________

When did you last work? ___________

Why did your last job end? _______________________________

Medical History:

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

List all medications which you currently take:

Medication Dose (m.g.) Times per day For what problem?

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

Have you ever been hospitalized overnight for medical reasons other than surgery? List your age when you were hospitalized and the reason.

Age: Reason:

Mental Health History:

Have you ever been placed in a psychiatric hospital? List your age when you were hospitalized and the reason.

Age: Reason:

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

Age when you How long did Reason you Type of therapist

Attended Sessions you attend? attended? (PhD, MD, School)

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 To help with Type of

was prescribed? what problem? medication?

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? __________

__________________________________________________________

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

When were you last charged with a crime? __________

Have you ever been in jail or prison? Yes No

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? _____

When did you have your last drink? ____________

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? __________

How old were you when you first used a drug? __________

Daily Functioning

Driving: Check the one which applies:

_____ I have never driven a car

_____ I still drive

_____ I used to drive a car but haven't since: ______________________

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: