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Adult History Form

Presenting Problem

Developmental, Educational, Occupational, Social History

Has the patient even been exposed to traumatizing events or circumstances?
Highest Level of Education
How would you best describe your grades? (If not applicable, please choose "N/A")
Was the patient in special education classes?
Have there been any problems with either your current or previous employer(s)?
Does the patient have children?
Is the patient living with others within the home?
Does the patient share a bedroom with another person or partner?
Are there any psychological problems of concern among current household members?
Have there been changes over the years in how patient related to others?

Medical History

Has the patient taken prescription medication in the past?
Is the patient currently taking prescription medication/

Legal

Are there any previous or current legal issues involving the patient?
Is there any court ordered therapy or testing being requested currently?

Summary

Add your text

Signature and Date

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