Adult Development HxDerek Judkins2019-07-12T10:07:55-05:00 Adult History Form Step 1 of 11 9% General InformationName* First Last Phone*Email* Date of Birth* Date Format: MM slash DD slash YYYY Gender*Nationality*Are you currently your own guardian?*YesNoReason 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 birthDid 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 deliveryMethod of delivery (vaginal, cesarean, forceps)Gestational ageAny history of foster care/orphanage care/CPS involvement?If adopted, Age at adoptionContact with biological parents?Additional comments Developmental HistoryWhich hand do you prefer*RightLeftDid you ever have any motor coordination difficulties (e.g. frequent falling, awkwardness)?*YesNoDid you have any difficulty in learning to talk or have any speech problems?*YesNoAt 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?*YesNoDo you have or have you had head injuries/concussions?*YesNoDo you have or have you had ear infections?*YesNoDo you have or have you had asthma?*YesNoDo you have or have you had cancer?*YesNoDo you have or have you had diabetes?*YesNoDo you have or have you had loss of consciousness?*YesNoDo you have or have you had high fever?*YesNoDo you have or have you had heart disease?*YesNoDo you have or have you had seizures?*YesNoDo you have or have you had lead poisoning?*YesNoDo you have or have you had any other Illness?*YesNoPlease describe treatment given and any complications for illnesses/injuries indicated aboveHave you ever been hospitalized?*YesNoDescribe any hearing or vision problemsList any previous surgeries, age, and length of hospitalizationOther medical historyDo 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 MedicationsFor what has this medication been prescribed?Side EffectsWho prescribes this medication?Previous medications & dates takenHas anyone in your family had a neurological disease?*YesNoHas anyone in your family had seizures (epilepsy)?*YesNoHas anyone in your family had psychiatric problems?*YesNoHas anyone in your family had emotional problems?*YesNoHas anyone in your family had alcoholism problems?*YesNoHas anyone in your family had substance abuse problems?*YesNoHas anyone in your family had language delays?*YesNoHas anyone in your family had motor (physical) delays?*YesNoHas anyone in your family had hyperactivity?*YesNoHas anyone in your family had learning problems?*YesNoHas anyone in your family had autism spectrum disorders?*YesNoHas anyone in your family had similar problems to child?*YesNo Evaluations & ServicesFor each category, please list any previous evaluations, examiners, dates, and results, as well as current providers.Pediatrician or Family DoctorTelephoneFaxTherapist/Examiner's NameTitleTelephoneFaxDates of Last Evaluation/SessionsDate of Occupational Therapy/Physical Therapy/Speech & Language EvaluationClinic Name & Examiner’s NameTherapy: Dates attendedDate of Last Vision/Hearing ExaminationNeurologist's NameDate of Last ExaminationCounty Social Worker/Case Manager NameTelephoneFax SchoolName of Current SchoolHave you ever completed an evaluation through school (e.g., to qualify for special education)?YesNoName of PreschoolDates AttendedConcernsName of Elementary SchoolDates AttendedConcernsName of Middle/Junior High SchoolDates AttendedConcernsName of High SchoolDates AttendedConcernsName of Post High SchoolDates AttendedConcernsName of Post High SchoolDates AttendedConcernsHave you received Title 1 services?*YesNoHave you had a 504 plan?*YesNoHave you had an IEP (special education services)?*YesNoHave you received tutoring?*YesNoCheck the word that best describes your child’s grades throughout his/her school experience:*SuperiorAbove AverageAverageBelow AverageFailingDuring 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?*YesNoHave you used cannabis?*YesNoHave you used meth?*YesNoHave you used other drugs?*YesNoHave you ever participated in inpatient or outpatient Substance Use Disorder treatment?*YesNoDo you consume caffeine?*YesNo Legal HistoryHave you ever been charged of a crime?*YesNoAre you currently on probation?*YesNo Interpersonal RelationshipsRelationship statusSexual Orientation/Gender Identity
