Adult History Information Adult History Information LinkedInThis field is for validation purposes and should be left unchanged.Adult History Questionnaire Please answer all questions AS FULLY AS POSSIBLE and bring with you on the day of your appointment Name of person completing formRelationship to patientPatient’s full nameDOB MM slash DD slash YYYY AgeSex Male Female Transgender Non-binary/Non-Conforming Prefer not to say Are you Right-handed Left-handed What do you consider to be your ethnicity?Where did you grow up?BirthplaceMarital Status Single Married Life Partner Divorced Widowed How long?How long?How long married?How long divorced?How long married?How long widowed?Please list names & ages of all childrenWho lives in your home?What is (are) your source(s) of income? Employment SSI General Assistance Retirement/Pension SSDI Food Stamps Other OtherIf you have applied for disability: Was it granted? Yes No If yes, when granted?What was the application based on?Did you learn English as your first language? Yes No At what age did you learn English?What is your preferred/primary language now?Current Concerns/Symptoms For each item below, place a mark in the “Past” box if this was a problem for you in the past, and place a mark in the “Current” box if it is currently a problem for you (you can mark both “Past” and “Current” if necessary): AttentionEasily distracted Past Current Have to reread material Past Current Losing train of thought Past Current Trouble following conversations Past Current Losing or misplacing personal items (e.g., glasses, keys, phone) Past Current Trouble multitasking Past Current Trouble planning complex activities (e.g., a party or vacation) Past Current Trouble organizing your things Past Current Trouble planning your day Past Current Procrastinating Past Current Daydreaming or mind wandering Past Current Trouble following multi-step instructions (e.g., a recipe) Past Current Trouble making decisions quickly Past Current Leaving projects unfinished Past Current Trouble getting started on things Past Current Trouble getting back on track if interrupted Past Current SpatialGetting lost easily while driving, in stores or walking in your neighborhood Past Current Trouble reading maps Past Current Trouble judging distances Past Current Unsure of your body position (e.g., bumping into things, misreaching for objects) Past Current Everyday ActivitiesDifficulty driving (e.g., running lights, accidents, hitting curbs) Past Current Trouble remembering to take medications Past Current Trouble managing your finances (e.g., forgetting to pay bills) Past Current Trouble cooking (e.g., forgetting to turn off stove, leaving ingredients out) Past Current Trouble with housekeeping (e.g., dishes, cleaning, laundry) Past Current Trouble with bathing, grooming, dressing (e.g., need help shaving, reminders to brush teeth) Past Current MemoryTrouble remembering people’s names Past Current Trouble recognizing familiar faces Past Current Trouble remembering recent events (e.g., what you had for dinner last night) Past Current Trouble remembering recent conversations Past Current Trouble remembering things from longer ago (e.g., couple years ago) Past Current Trouble learning new things Past Current Having to write notes to remember things a lot more than usual Past Current Repeating yourself Past Current LanguageTrouble thinking of the right word (“tip-of-thetongue”) Past Current Using the wrong word Past Current Trouble understanding what others are saying in conversation Past Current Slurred speech or problems w/articulation Past Current Fine MotorTrouble picking up or dropping things Past Current Trouble assembling pieces (e.g., furniture) or using tools Past Current Changes in your handwriting Past Current Tremors or shakiness in hands/arms or other body parts Past Current Numbness/tingling in hands or feet Past Current SensoryChange in vision Past Current Change in hearing Past Current Change in taste or smell Past Current Change in touch sense Past Current Walking/BalanceFeeling uncoordinated Past Current Problems with balance Past Current Falling down Past Current Feeling dizzy or lightheaded Past Current Trouble with or change in your walking Past Current Are there any other changes or problems with your thinking? Please describe:Are any of the difficulties described above interfering with your ability to carry out daily activities at home, work, school, or socially? Please explain:Are there any current or ongoing stressors in your life (e.g., work, marital/partner stress, problems with coworkers, family member’s poor health, problems with grown children)? Please explain:Trauma can come in many forms and affects individuals differently. For the purpose of understanding your experiences and providing the best support, we're interested in learning about any past events that have been particularly distressing or challenging for you. Below is a list of experiences that might qualify as traumatic. This list is not exhaustive but serves as a guide. Please share any experiences that you feel comfortable discussing, keeping in mind that you can skip any question that makes you feel uncomfortable. Directly experiencing a serious injury, sexual violence, or a life-threatening event Witnessing, in person, an event where others were seriously injured, killed, or subjected to sexual violence Learning that a violent or accidental event occurred to a close family member or close friend Experiencing repeated or extreme exposure to aversive details of traumatic events (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse) Please describe any events you are comfortable sharing, including when they happened, how they impacted you at the time, and whether they continue to affect you. Remember, there is no right or wrong answer; your experiences are valid.Psychiatric/Emotional History For each item below, place a mark in the “Past” box if this was a problem for you in the past, and place a mark in the “Current” box if it is currently a problem for you (you can mark both “Past” and “Current” if necessary):Hearing things or seeing things that other people don’t Past Current Hoarding Past Current Unexplained inability to move parts of your body Past Current Racing thoughts Past Current Pressured Speech/More talkative than usual Past Current Decreased or absent need for sleep Past Current Frequent or extreme mood swings Past Current Problems with temper or “rage attacks” Past Current Depression (e.g., sadness, increased crying, feeling “blue”) Past Current Extreme fears or phobias Past Current Social anxiety (e.g., talking in public, eating in front of other people) Past Current Panic attacks Past Current Frequent or excessive worry Past Current Obsessive thoughts or compulsive behaviors Past Current Pulling out hair or eyelashes, or skinpicking Past Current Exposure to a life-threatening event (e.g., war, rape, physical assault) Past Current Frequent nightmares Past Current Flashbacks Past Current Feeling detached from your body (“outof-body experience”) Past Current Eating Disorder (e.g., anorexia, bulimia, binge-eating) Past Current How would you describe your current mood (e.g., happy, sad, angry, nervous)?Have you ever been hospitalized for emotional/psychiatric difficulties? No Yes Have you ever received outpatient treatment for emotional or psychiatric problems (e.g., school counselor, psychotherapy, marriage counseling, etc.)? No Yes IF YES ➔Are you currently in counseling?Do you have a history of physical, sexual or emotional abuse (including domestic violence)? No Yes Has anyone ever pressured you or influenced you to give/transfer funds, real estate, or your personal property to them? No Yes Have you ever taken medication for psychiatric problems? No Yes IF YES ➔ Please list medication name, dose and note if past or current:Have you ever thought about or attempted suicide? No Yes IF YES ➔Are you currently having any suicidal thoughts or behaviors? No Yes Do you feel safe in your home? No Yes Developmental HistoryWere you born On time Early Late Early (how early?)Late (how late?)What was your weight at birth?Were there any complications during your mother’s pregnancy or delivery with you?IF YES ➔ Gestational diabetes High blood pressure High fever Injuries/accidents Other Other: (please describe)While she was pregnant with you, did your mother use: Alcohol Cigarettes Drugs N/A To the best of your knowledge, were you delayed in any of the following areas? Walking Talking Toilet training Please list any serious injuries, infections, or surgeries you had as a child (e.g., seizures, measles, mumps, rheumatic fever).As a child or teenager, did you have any of the following?Please mark all that are applicable: Academic learning problems Poor listening skills Memory problems Poor concentration or short attention span Problems with walking or handwriting Poor organization Bed wetting Distractibility Poor peer relations Poor judgment Repetitive behaviors/tics Poor temper or impulse control Anxiety/fears Poor frustration tolerance Depression Excessive fighting Suicidal ideation Alcohol/drug abuse Self-harm/cutting Running away Eating disorder Difficulties with the law Unusual beliefs/delusions Fire setting Hallucinations Truancy Hyperactivity Cruelty to animals Bullying others Property destruction Academic, Employment, & Social HistoryPlease indicate the highest level of education you have completed: 6th – 8th grade 9th – 11th grade 12th grade/high school diploma GED Some college: 1 year Some college: 2-3 years Associate’s Degree Bachelor’s Degree Master’s Degree Doctoral Degree Associate’s Degree (please specify major/concentration)Bachelor’s Degree (please specify major)Master’s Degree (please specify concentration)Doctoral Degree (e.g., MD, PhD, JD – please specify)Did you receive any special education services, resource room services, or tutoring services in school? Yes No Did you ever have to repeat a grade? No Yes Please specify which grade(s)Did you ever skip a grade? No Yes Please specify which grade(s)Did you have trouble learning to read? No Yes Did you have trouble learning basic math? No Yes Are you currently employed? No Yes Where do you work?What is your job title?How long have you been at this job?How many hours per week do you work?Have you been employed in the past?If so, where did you work and what was your title?How long did you work at that job?When was the last date you were employed?Have you ever been arrested? No Yes Do you currently have any legal problems (parole, probation, etc.)? No Yes Do you have any lawsuits pending or do you intend to sue in the near future? No Yes Medical History Please check all the following that apply to you:Who is your General Practitioner?Do you have any Medical Specialist you currently see?Asthma Past Current Metabolic Disorders Past Current Brain Tumor Past Current Multiple Sclerosis Past Current Cancer Past Current Obesity Past Current Heart disease or heart attack Past Current Stroke Past Current Diabetes Past Current TIA (“mini-stroke”) Past Current Headaches Past Current Seizure Past Current High Blood Pressure Past Current Toxic Exposure Past Current High Cholesterol Past Current Thyroid Problem Past Current Kidney Disease Past Current HIV/AIDS Past Current Lupus Past Current Pulmonary (Lung) disease Past Current Liver Disease Past Current Other Past Current Meningitis/Encephalitis Past Current Other (Past)Other (Current)Do you currently smoke cigarettes? No Yes Have you ever smoked cigarettes in the past? No Yes On average, how many cigarettes do you smoke per day?How long have you smoked?Have you ever used recreational drugs? No Yes Please check all the following that apply to you, either past or current (or both if applicable):Marijuana or Spice Past Current Heroin Past Current Cocaine (including crack cocaine) Past Current PCP Past Current Methamphetamine/Crystal Meth Past Current Inhalant (e.g., “huffing”) Past Current Other hallucinogen (e.g., LSD, acid, psilocybin/mushrooms, peyote) Past Current Prescription pain medications (not as prescribed) Past Current Other Past Current Other (please describe)Do you currently drink alcohol? No Yes If yes, on average, how many drinks do you have per week?Have you ever had periods of heavy alcohol use in the past? No Yes Have you ever had a head injury No Yes Please list date(s)After the head injury, did you experience any of the following? Loss of consciousness Blurred vision/double vision Dizziness Nausea Vomiting Headaches Changes in taste or smell Loss of consciousness (if yes, how long?)Did you seek medical treatment? No Yes Were you admitted to a hospital? No Yes If yes, how long?Did you have a head CT or MRI scan?What medications do you currently take? Please list dose if known.Have you ever received psychological, neuropsychological, or cognitive testing? No Yes If yes, please list:Date(s)DoctorFacility or location Add RemoveHave you ever receivedPhysical therapy No Yes Occupational therapy No Yes Speech therapy No Yes Have you ever had surgery (please list)?Do you have any trouble sleeping? No Yes Is it hard for you to fall asleep? No Yes Is it hard for you to stay asleep? No Yes What time do you usually go to bed?What time do you usually wake up?Do you take any medications or supplements to help you sleep? No Yes If yes, please listAre you tired during the day or do you take naps? No Yes Do you snore? No Yes Do you have sleep apnea? No Yes Do you use a CPAP or BiPAP machine? No Yes Do you ever stop breathing or wake up gasping for air when asleep? No Yes Do you have frequent vivid dreams or nightmares? No Yes Are you a restless sleeper or do you have restless leg syndrome? No Yes Do you experience chronic pain? No Yes Where is the pain located in your body?Are you in any pain right now? No Yes Where is the pain located in your body?Have you tried any pain treatments (e.g., massage, acupressure/acupuncture, medications)? No Yes If yes, how helpful have the treatments been?FAMILY HISTORY Please indicate whether any members of YOUR biological family (blood relatives only – do not include stepfamily or people related to you by marriage) had any of the following (including children, brothers, sisters, parents, grandparents, aunts, uncles, cousins):Family History Alzheimer’s disease or other dementia Schizophrenia/Schizoaffective Disorder Anxiety disorder (e.g., panic attacks, phobias) Autism Spectrum Disorder Bipolar Disorder (Manic Depression) Attention-Deficit/Hyperactivity Disorder Major Depression Seizure Disorder (Epilepsy) Learning Disabilities Stroke or TIA (“mini-stroke”) Memory Problems Alcohol or drug abuse/dependence Intellectual Disability (mental retardation) Suicide Parkinson’s disease Huntington’s disease Psychiatric Hospitalization Other Is there anything else that you would like to add?Name and phone number of emergency contactRelationshipPreferred Email Digital Signature
