Adult History Form "*" indicates required fields Step 1 of 11 9% General InformationName* First Last Phone*Email* Date of Birth* MM slash DD slash YYYY Gender* Nationality* Are you currently your own guardian?* Yes No Reason for referral: What are your primary concerns?* Stressors and Abuse HistoryHave there been any recent stressful life events? (Check all that apply) Divorce/Separation Financial Problems Substance Abuse Death of Family/Friend/Pet Marriage Change in Job Status Disagreement About Parenting Relationship Conflict Sibling Conflict Other Have there been any abuse or trauma experienced? (Check all that apply) Physical Abuse Sexual Abuse Emotional Abuse Verbal Abuse Bullying Life-Threatening Situation Other Trauma Birth HistoryMother’s age at time of your birth Did mother receive prenatal care? Medications taken during pregnancy? (Please specify) Were any of the following used during pregnancy? (Including prior to knowledge of the pregnancy) Alcohol Marijuana Tobacco Methamphetamines Other Drugs Please explain any complications during pregnancy, labor or delivery Method of delivery (vaginal, cesarean, forceps) Gestational age Any history of foster care/orphanage care/CPS involvement? If adopted, Age at adoption Contact with biological parents? Additional comments Developmental HistoryWhich hand do you prefer* Right Left Did you ever have any motor coordination difficulties (e.g. frequent falling, awkwardness)?* Yes No Did you have any difficulty in learning to talk or have any speech problems?* Yes No At what age did you develop gross motor skills (crawling, walking)? At what age did you develop fine motor skills (fingers / hands)? At what age did you develop communication skills? At what age did you develop self-care (dressing self, taking care of hygiene)? At what age did you develop social skills? At what age did you develop education skills (alphabet, numbers)? At what age were you toilet trained? Additional Comments Medical HistoryDo you have or have you had meningitis?* Yes No Do you have or have you had head injuries/concussions?* Yes No Do you have or have you had ear infections?* Yes No Do you have or have you had asthma?* Yes No Do you have or have you had cancer?* Yes No Do you have or have you had diabetes?* Yes No Do you have or have you had loss of consciousness?* Yes No Do you have or have you had high fever?* Yes No Do you have or have you had heart disease?* Yes No Do you have or have you had seizures?* Yes No Do you have or have you had lead poisoning?* Yes No Do you have or have you had any other Illness?* Yes No Please describe treatment given and any complications for illnesses/injuries indicated above Have you ever been hospitalized?* Yes No Describe any hearing or vision problems List any previous surgeries, age, and length of hospitalization Other medical history Do you frequently have problems with (check all that apply) Headache Weakness Fatigue or Sleep Issues Dizziness Nausea Wetting/Soiling Accidents Stomach Aches Diarrhea Muscle Tension Current Medications For what has this medication been prescribed? Side Effects Who prescribes this medication? Previous medications & dates taken Has anyone in your family had a neurological disease?* Yes No Has anyone in your family had seizures (epilepsy)?* Yes No Has anyone in your family had psychiatric problems?* Yes No Has anyone in your family had emotional problems?* Yes No Has anyone in your family had alcoholism problems?* Yes No Has anyone in your family had substance abuse problems?* Yes No Has anyone in your family had language delays?* Yes No Has anyone in your family had motor (physical) delays?* Yes No Has anyone in your family had hyperactivity?* Yes No Has anyone in your family had learning problems?* Yes No Has anyone in your family had autism spectrum disorders?* Yes No Has anyone in your family had similar problems to child?* Yes No Evaluations & ServicesFor each category, please list any previous evaluations, examiners, dates, and results, as well as current providers.Pediatrician or Family Doctor TelephoneFaxTherapist/Examiner's Name Title TelephoneFaxDates of Last Evaluation/Sessions Date of Occupational Therapy/Physical Therapy/Speech & Language Evaluation Clinic Name & Examiner’s Name Therapy: Dates attended Date of Last Vision/Hearing Examination Neurologist's Name Date of Last Examination County Social Worker/Case Manager Name TelephoneFax SchoolName of Current School Have you ever completed an evaluation through school (e.g., to qualify for special education)? Yes No Name of Preschool Dates Attended Concerns Name of Elementary School Dates Attended Concerns Name of Middle/Junior High School Dates Attended Concerns Name of High School Dates Attended Concerns Name of Post High School Dates Attended Concerns Name of Post High School Dates Attended Concerns Have you received Title 1 services?* Yes No Have you had a 504 plan?* Yes No Have you had an IEP (special education services)?* Yes No Have you received tutoring?* Yes No Check the word that best describes your child’s grades throughout his/her school experience:* Superior Above Average Average Below Average Failing During school have you experienced problems with (check all that apply) Reading Arithmetic Social Adjustment Writing Attention Span Following Directions Spelling Activity Level Truancy Suspension Detention Other Emotional/Behavioral ConcernsDo you have a history or currently struggle with (check all that apply) Depression/Sad Mood Anxiety/Worries/Nervousness Anger Attention and Focus Issues Significantly Elevated Moods Ritual or Routine Behaviors Obsessive Thinking Hallucinations Suicidal Ideation Self-Harm Behaviors Homicidal Ideation Rule Breaking Argumentative Social Concerns Hyperactivity Temper Tantrums Irritability Panic Attacks Impulsivity Distressing Memories Separation Issues Complains of Physical Symptoms Nightmares Eating Issues Gambling Sexual Concerns Identity Concerns Substance Use HistoryHave you used alcohol?* Yes No Have you used cannabis?* Yes No Have you used meth?* Yes No Have you used other drugs?* Yes No Have you ever participated in inpatient or outpatient Substance Use Disorder treatment?* Yes No Do you consume caffeine?* Yes No Legal HistoryHave you ever been charged of a crime?* Yes No Are you currently on probation?* Yes No Interpersonal RelationshipsRelationship status Sexual Orientation/Gender Identity PhoneThis field is for validation purposes and should be left unchanged.
