Adult History FormCJHTadmin2021-06-01T11:54:38+00:00 Adult History form Please Take your time and fill in compltelyName(Required) Date of Birth(Required) MM slash DD slash YYYY Age(Required) Soc.Sec# Address City State / Province / Region ZIP / Postal Code Home Phone Work Phone Cell Phone(Required) occupational backgroundCurrent Occupation How Long Describe any dissatisfaction or problems in your present jobList previous jobs and time spent working in each oneeducational backgroundHighest grade completed College degrees obtained Describe any academic or behavior problems you had in schoolFamily Of origin HistoryCity of birth In what city were you raised? How many times did you move prior to leaving your parent's home? How many children were in your family? which one were you? Who were you closest to in your family? most distant from? Describe your relationship with each of your parentsProblems experienced during child and teen years Describe any mental illness,substance abuse or legal problems in your family of originCurrent Family HistoryMarital status(check all that apply) single,never married separated divorced widowed How long? How many times have you been married? Please complete the following information about each of your childrenNameSexAgeResidenceDescribe Your Relation with each child Add RemovePsychological HistoryHave you ever considered or attempted suicide? DescribeDescribe any emotionally disturbing experiences you have had:Describe what has been stressful for you in the past year:Have you ever been arresrted? If yes,what were the charges? Have you ever been physically abused? If yes,at what ages: Have you ever been sexually abused? If yes,at what ages: Symptom Checklist 1. Please check each symptom experienced within the past two months 2. Then Circle your worst symptoms(six to eight).Symptom Checklist Depressed mood Feel worthless Hopeless or helpness Mood swings Socially withdrawn Increase crying Suicidal attempt Memory problem Temper outbursts Insomnia Thoughts of death Low self-esteem Easily startled Easily fatigued Sleeps too much Binge eating stealing Dramatic Other Problem Obsessive thoughts Compulsive behavior Nightmares Anxiety/Worry Intense fear Short attention span Hyperactivity Impulsive Perfectionist Change of appetite Poor concentration Easily distracted Avoids crowds Muscle tension Panic attacks Easily confused Makes self vomit Fire setting Avoids conflict Exposed to life threatening event Hears voices Sees things that are not there Racing thoughts Increased energy Sexual problem Stomach aches Headaches Conflicts with peers Rapid heart beat Reckless or self-abusive behavior Conflicts with others Aggressive behavior Less interested in fun activities More talkative Believe that others are plotting against you Constantly on the watch for danger Feels like things are not real Fears gaining weight Gambling problem Hair pulling Enjoys being center of attention Social HistoryDescribe your friendships as a childHow many close friends do you now have? Describe your best friendWhat do you like do with your friends? Involvement in social oraganizations(i.e church,clubs,organizations) Health History(please fill in completely,even if some things do not seem important)Illness & HospitalizationsAgeLengthFever-Unconscious?Treatment & Aftereffects Add RemovelistAccidentsAgeUnconscious?reatment & Aftereffects Add RemoveListList all medications you are now takingName of Dr.prescribingPurpose of medication Add RemoveListList all psychiatric medications you have taken in the pastName of Dr.prescribingPurpose of medication Add RemoveList all your current medical problemsName of your primary physician Physician's address and phone numberDescribe any weight loss or gain in the past yearDescribe how much you excerciseHow much do you smoke? Date of last physical exam Describe any sleep difficultiesHead injuries? ExplainHave You ever had a seizure? If yes,describeHow much alcohol do you drink on weekly basis? What other non-prescription drugs have you used? Have you ever been charged with a D.W.I or D.U.I? Ages or years ReligiousDescribe your religious upbringingChurch affiliation Describe your level of participation in religious activitiesDescribe how you would feel about discussing spiritual or religious issues as a part of your evalution or therapyCounseling & Therapy HistoryDescribe any previous psychological or psychiatric evalutionDescribe any previous involvement with therapy or counselingTreatment GoalsDescribe the problem that troubles you the most(Required)Why are you coming in for therapy(versus before or later)? What goals do have for therapy? Signature(Required) Date(Required) MM slash DD slash YYYY
