Adolescent & Adult

Client Health Information

Name: Age: Today’s Date: _____________
CIRCLE ANY YOU HAVE EXPERIENCED RECENTLY:
Feel sad, blue, Change of Feel bad about self Feel tired a lot
depressed appetite
Don't enjoy things Poor Crying spells Lowered sex drive
concentration
Problems with sleeping Gained/lost Feelings of Others
weight hopelessness

MARK YES OR NO:

❑ Yes ❑ No Do you think about hurting or killing yourself?
❑ Yes ❑ No Do you think about hurting or killing another person?
❑ Yes ❑ No Do you feel anxious, nervous, or stressed much of the time?
❑ Yes ❑ No Have you ever been so anxious that you had trouble breathing?
❑ Yes ❑ No Are you deathly afraid of anything (snakes, thunderstorms, animals, heights, etc.)?
❑ Yes ❑ No Do you ever picture things in your mind that disturb you and are not related to a real life
problem?
❑ Yes ❑ No Is there anything that you do (such as checking locks, washing hands, cleaning things) a
lot more than other people?
❑ Yes ❑ No Do you worry all the time?
❑ Yes ❑ No Do you ever have times you felt unusually good or do very impulsive things?
❑ Yes ❑ No Have you ever seen or heard something that might not be there?
❑ Yes ❑ No Do you ever think or believe things that others say are not possible or real?
❑ Yes ❑ No Do you smoke? How much do you smoke?
❑ Yes ❑ No Do you drink alcohol? How much do you normally drink in a week?
❑ Yes ❑ No Do you use recreational drugs? How often?
❑ Yes ❑ No Have you had a driving under influence (DUI)? When?
❑ Yes ❑ No Have others (family, doctor, employer) expressed concern about your smoking, drinking, or
using of drugs?

MARK þ IF ANYONE IN THE FAMILY YOU GREW UP WITH HAS EXPERIENCED:

❑ Nervous ❑ Depression ❑ Attempted or committed suicide ❑ Prison
problems
❑ Anxiety ❑ Drinking ❑ Medication for mental health ❑ Drug
reasons use
❑ Divorce ❑ Abuse ❑ Hospitalized for mental health
reasons

MARK þ THE APPROPRIATE ANSWER:

❑ Yes ❑No Were you abused in any way as a child?
❑ Yes ❑No Have you ever experienced any type of unexpected or traumatic event?
❑ Yes ❑No Do you have any current concerns about your physical safety?
❑ Yes ❑No Did you lose a parent through death during childhood?
❑ Yes ❑No Do you have religious beliefs and thoughts that affect your living?
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❑ Yes ❑No If married or in a serious relationship, are you satisfied with it?
❑ Yes ❑No Are there sexual matters that concern you?
❑ Yes ❑No If employed, do you like your job?
❑ Yes ❑No Is your health good?

IF MARRIED OR IN A SERIOUS RELATIONSHIP, TICK ANY THAT APPLY:

❑ Frequent arguments ❑Poor communication ❑Poor sexual relationship ❑Infidelity
❑ Unresolved issues ❑Periods of withdrawal ❑Physical abuse

PLEASE TICK IF YOU HAVE:

❑ shortness of breath ❑pins and needles ❑backache ❑cough seizures
❑ bowel problems ❑dizziness ❑stomach ache ❑palpitations
❑ diarrhea ❑vomiting ❑sweating ❑ headaches

1. When was your last physical medical checkup? __________________________

2. What is the primary reason you are seeking therapy at this time?

_____________________________________________________________________________

_____________________________________________________________________________

FAMILY PSYCHIATRIC HISTORY

Please indicate any family members on either side who have had any of the following:
MEDICAL PROBLEMS MOTHER’S SIDE FATHER’S SIDE
Intellectual disability
Learning disabilities/problems
Hyperactivity/attention problems
Speech/language problems
Seizures
Headaches
Genetic disorders
Miscarriages
Multiple Sclerosis
Tourette’s syndrome
Thyroid problems
Other medical problems
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PSYCHIATRIC PROBLEMS MOTHER’S SIDE FATHER’S SIDE

Depression/suicide
Bipolar disorder (Manic-
Depression)
Anxiety disorder
Panic attacks
Obsessive-compulsive disorder
Phobias and fears
Autism spectrum disorder
Schizophrenia
Hallucinations
Alcohol/drug abuse (specify)
“Nervous breakdowns”
Other

CHILDHOOD AND DEVELOPMENTAL HISTORY

3. Pregnancy, Delivery and Birth:
Were there any problems during your mother’s pregnancy with you or at your birth? If so, please
describe:

4. Developmental History:
Were there any problems during your development, such as delayed walking,
talking, or problems relating to others? If so, please describe:

PERSONAL MEDICAL HISTORY

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PERSONAL AND FAMILY MEDICAL HISTORY

5. List any medications currently prescribed to you, dosages and reason for the
medication:

Medication: _________________________________________________________

Dosage: ___________________________________________________________

Reason: ___________________________________________________________

6. Please indicate and describe your current and past health problems:
Health Problems Age Duration (How many Treatment
days/months/years?)
Headaches
Seizures
Head injury
Loss of consciousness
Meningitis
Encephalitis
Brain tumor
Paralysis
High fever
Fainting spells
Coma
HIV infection/AIDS
Near drowning
Electric shock
Drug/alcohol abuse
Psychiatric
hospitalization
Psychological
counseling
Legal problems/arrests
Others (Please specify:
___________________)
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7. If you have suffered head injury, please describe the incident:

Date of the incident:
Did you suffer loss of consciousness? For how long?
Did you have amnesia of events before the incident? ______________________
After? Did you remember the
incident itself?
Were you treated by a doctor? Hospitalized?
Describe the length and course of the hospitalization: ___________________________

Indicate the neurodiagnostic procedures performed:

a) CT or brain scan
b) MRI of brain
c) EEG _________________________________________________________________
d) Lumbar puncture (spinal tap)
e) Other (PET, SPECT, etc.) _________________________________________________

8. Please indicate and describe whether you currently or in the past have experienced or
complained of the symptoms listed below. Please tick yes if the problem is ongoing
and no if the problem has been resolved or symptom is absent.

Physical Symptoms:
a) Sensitivity to noise ❑ Yes ❑ No
b) Sensitivity to light ❑ Yes ❑ No
c) Ringing in the ears ❑ Yes ❑ No
d) Dizziness ❑ Yes ❑ No
e) Nausea/vomiting ❑ Yes ❑ No
f) Blurred vision ❑ Yes ❑ No
g) Double vision ❑ Yes ❑ No
h) Hearing problems ❑ Yes ❑ No
i) Problems with taste or smell ❑ Yes ❑ No
j) Numbness or tingling in extremities ❑ Yes ❑ No
k) Sleep problems ❑ Yes ❑ No
i) Fatigue ❑ Yes ❑ NO
Adolescent & Adult

Psychological Symptoms:
a) Depression ❑ Yes ❑ No
b) Mood swings ❑ Yes ❑ No
c) Irritability ❑ Yes ❑ No
d) Anger ❑ Yes ❑ No
e) Aggression ❑ Yes ❑ No
f) Low frustration tolerance ❑ Yes ❑ No
g) Can’t handle stress ❑ Yes ❑ No
h) Anxiety ❑ Yes ❑ No
i) Panic attacks ❑ Yes ❑ No
j) Paranoia ❑ Yes ❑ No
k) Hate to be in crowds ❑ Yes ❑ No
l) Social withdrawal/social problems ❑ Yes ❑ No
m) Hallucinations ❑ Yes ❑ No
n) Personality change ❑ Yes ❑ No
o) Difficulty with change ❑ Yes ❑ No

Cognitive Symptoms:
Memory
a) Poor short-term memory
b) Poor long-term memory
Reasoning
a) Reasoning problems
b) Take things too literally
c) Difficulty understanding consequences of actions
Language
a) Problems understanding what others say
b) Say “what” a lot
c) Need frequent repetition to understand
d) Do not listen
e) Can’t follow a 3-step command
f) Trouble expressing self verbally
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g) Talk too much or too little

h) Problems finding the right word to say
i) Stutter
Visuospatial
j) Trouble with visual tasks (e.g., puzzles, games, etc.)
k) Poor drawing ability
l) Poor penmanship
m) Get lost frequently
n) Have trouble with directions
Other
o) Attention problems
p) No concept of time
q) Clumsy, poor motor skills
r) Drop in school performance (which subjects and when?
Additional information:
Please provide any other information or describe any other concerns that have not been covered in this
Adolescent & Adult