Adult History Form

Patient Last name

Patient First name

Presenting Problem

What are the symptoms of concern?

When do they tend to occur and how often?

What has been done to treat the symptoms? What types of procedures, programs, or services have you sought?

How successful have previous treatments been?

Developmental, Educational, Occupational, Social History

Has the patient even been exposed to traumatizing events or circumstances?

If "yes" to previous questions, please provide details.

Describe specific current symptoms associated with trauma.

Describe patient's childhood. (Please list any specific happy, sad, or noteworthy events. Describe how patient got along with his/her parents.

How did patient get along with his / her parents.

Did patient's parents or extended family have any problems? If so, please describe.

Highest Level of Education

How would you best describe your grades? (If not applicable, please choose "N/A")

Please list schools and years attended

Was the patient in special education classes?

If "yes" what type(s) of services did the patient receive?

Please list employment history.

Have there been any problems with either your current or previous employer(s)?

If "yes" to the previous question, please describe.

What is current work schedule?

Does the patient have children?

If "yes" to previous question, who provides care for child(ren) when patient is not at home?

Is the patient living with others within the home?

If "yes" to previous question, who are they and what is the relationship?

If applicable, do members of the household and / or family get along well? Is there unanimity in parenting if children are involved - if not, what are the major differences?

Describe the patient's residence. How many bedrooms?

Does the patient share a bedroom with another person or partner?

If "yes" to previous question, what is the relationship.

Are there any psychological problems of concern among current household members?

If "yes" to previous question, please describe if any treatment being received.

Describe how the patient gets along with others outside the family.

Have there been changes over the years in how patient related to others?

If "yes" to previous question, please describe.

Medical History

Please list any serious illnesses involving the patient. (please include dates if known)

Please list any surgeries involving the patient. (please include dates if known)

Please list any treatments / interventions involving the patient. (please include dates if known)

Has the patient taken prescription medication in the past?

If "yes" to previous question, please list all medications and periods during which they were taken.

Is the patient currently taking prescription medication/

If "yes" to previous question, please list all current medications, dosage levels, and how often they are administered.

Legal

Are there any previous or current legal issues involving the patient?

If "yes" to previous question, please specify what they are, including: the court of jurisdiction, the charges involved, the name of any attorney(s) involved, the name of any CASA worker of Guardian ad Litem, the name of any probation officer.

Is there any court ordered therapy or testing being requested currently?

If "yes" to previous question, please list any deadlines.

Summary

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List the goals expected as a result of the therapy and / or assessment services being offered.

If applicable, please describe any additional concerns.

Signature and Date

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info@associatedclinical.com

703 - 569 - 8731

Adult History Form

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