ADULT PSYCHOLOGICAL HISTORY
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- Lynette Craig
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1 ADULT PSYCHOLOGICAL HISTORY Name: Date of Birth: Address Why I came for this visit: Who lives with you? Occupation: [ ] Live alone [ ] Spouse [ ] Partner Education: [ ] High School [ ] Some College [ ] Live with roommate(s) [ ] Live with my kids [ ] Graduated College - A.A. B.A. B.S. SYMPTOM CHECKLIST [ ] Other [ ] Advanced Degree - Master s, Doctorate 0 This symptom not present at this time [ ] Certificate in My Field 1 = This symptom is present, bothers you a little, but not enough to be a problem 2 Symptom present, bothers you and affects your quality of life, but able to function OK 3 Moderate impact on quality of life and/or day-to-day functioning 4 = Significant impact on quality of life and/or day-to-day functioning 5 Serious impact on quality of life, interferes with day-to-day functioning Symptom Severity Symptom Severity Symptom Severity Depressed Mood Hearing/Seeing Things Guilty Feelings Worrying Feel I m Being Watched Lump in Throat Difficulty Concentrating Feel Others Are Against Me Heart Racing Angry Feelings Loss of Interest in Things Twitches, Spasms Angry Behavior Temper Outbursts Knot in Stomach Anxious/Nervous Feelings Thoughts Coming Too Fast Fear of Places Panic Attacks Trouble Remembering Things Grinding of Teeth Mind Going Blank Thoughts of Hurting Myself Back Pain Poor Appetite/Weight Loss Thoughts of Killing Myself Nausea Easily Annoyed/Irritated Tiredness / Fatigue - Daytime Cry Easily Difficulty Falling Asleep Sleeping Too Much Chest Pain Difficulty Staying Asleep Excessive Weight Gain Sweaty Palms Difficulty Waking Up Excessive Weight Loss Avoid People
2 ADULT PSYCHOLOGICAL HISTORY Name: Page 2 Have you ever been in counseling or seen a psychiatrist before? Yes No Name of Practitioner Address of Practitioner Phone When? How many Times? Has any other family member seen a counselor or psychiatrist? Yes No Which Family Member? Relationship to You? What was counseling for? Were you ever in a hospital for a psychiatric problem, or rehab for a drug/alcohol problem? Yes No Name of Facility City and State of Facility Facility Phone When Were You There? For How Long? Has any other family member been in a program for a psychiatric or substance use disorder? Yes No Which Family Member? Relationship to You? What was it for? Has any family member used psychiatric medications?
3 ADULT PSYCHOLOGICAL HISTORY Name: Page 3 FAMILY HISTORY Who was present during childhood? Parents' current marital status: Describe your parents: Entire Part of NOT [ ] still married to each other Father Mother Time Time at all [ ] separated for years Name Mother [ ] [ ] [ ] [ ] divorced for years Work Father [ ] [ ] [ ] [ ] mother remarried times School Stepmother [ ] [ ] [ ] [ ] father remarried times Health Stepfather [ ] [ ] [ ] [ ] mother living with someone Describe your childhood family experience: Brother(s) [ ] [ ] [ ] [ ] father living with someone [ ] outstanding home environment Sister(s) [ ] [ ] [ ] [ ] mother deceased for _ years [ ] normal home environment Other: [ ] [ ] [ ] [ ] father deceased for years [ ] chaotic home environment Other was: [ ] witnessed physical/verbal/sexual abuse toward others Describe your relationship with a step-parent or parent s partner: [ ] experienced physical/verbal/sexual abuse from others Your family s economic status: Check all that characterize your childhood experience: [ ] Wealthy [ ] Poor [ ] Loving/Supportive [ ] Stable [ ] Variable [ ] Unstable [ ] Middle Class [ ] Welfare [ ] Verbally Abusive [ ] Parents Argued a Lot [ ] Emotionally Abusive [ ] Working Class [ ] Physically Abusive [ ] Little Memory of Childhood Difficult or Traumatic Events that happened during your childhood:
4 ADULT PSYCHOLOGICAL HISTORY Name: Page 4 Behavioral Health Problems - History of Family (check all that apply): Mother Father Sister Brother Aunt Uncle Children Grandparents Anger / Rage / Violence Alcohol / Drug Problems Anxiety / Worry Attention Deficit Bipolar / Mood Swings Depression Eating Disorder Obesity / Eating Obsessive or Hoarding Schizophrenia Suicide or Attempt Age of leaving family home: Reason for leaving: CURRENT FAMILY STATUS My Marital status: My Intimate relationship: List all persons currently living in your household: [ ] single, never married [ ] never been in committed relationship [ ] engaged months [ ] not currently in committed relationship [ ] married for years [ ] currently in a committed relationship [ ] divorced for years Relationship satisfaction: [ ] separated for years [ ] very satisfied with relationship [ ] divorce in process [ ] satisfied with relationship [ ] live-in for years [ ] partially satisfied with relationship Children who visit: prior marriages (self) [ ] dissatisfied with relationship prior marriages (partner) [ ] very dissatisfied with relationship Describe any past or current problems in committed or romantic relationships:
5 ADULT PSYCHOLOGICAL HISTORY Name: Page 5 Describe any past or current problems in family relationships: Do you feel that you have a purpose in life? Y N Were you raised with a religion? Y N Denomination? Do you currently attend religious activities? Y N Denomination? Do you currently practice any spiritual activities such as meditation, etc. Y N MEDICAL HISTORY (check all that apply) Describe current physical health: Is there a history of any of the following in your family: [ ] Excellent [ ] Good [ ] Fair [ ] Poor [ ] tuberculosis [ ] heart disease [ ] behavior problems List name of primary care physician: [ ] birth defects [ ] high blood pressure [ ] alcoholism Name Phone [ ] drug abuse [ ] thyroid problems [ ] diabetes List name of psychiatrist: (if any): [ ] cancer [ ] Alzheimer's disease/dementia Name Phone [ ] stroke [ ] mental disability Date of last Physical Exam: List any abnormal lab test results: Date Result Date Result [ ] other chronic or serious health problems: Describe any serious hospitalization or accidents you have had:
6 CHRONIC PAIN PROBLEMS (check all that apply) ADULT PSYCHOLOGICAL HISTORY Name: Page 6 Choose a number from 0-10 that best describes your ongoing pain (circle) Where is the pain located? When did the pain start? How long have you had this pain? How often do you experience pain? Does the pain affect activities (walking, shopping, exercise, etc)? What makes the pain increase? What makes the pain decrease? OTHER HEALTH ISSUES (check all that apply): Allergies? Food Allergies: Y N Medication Allergies: Y N Environmental Allergies: Y N Describe any health problems or issues you had during childhood: SOCIO-ECONOMIC SITUATION (check all that apply) Living situation: Social support system: Sexual history: [ ] housing is adequate [ ] supportive network [ ] heterosexual orientation [ ] NOT currently sexually active [ ] no stable home [ ] few or no friends [ ] homosexual orientation [ ] age of first sexual experience [ ] housing overcrowded [ ] distant from parents/siblings [ ] bisexual orientation [ ] history of promiscuity [ ] dependent on others [ ] isolate myself [ ] currently sexually active [ ] history of unsafe sex [ ] housing dangerous/deteriorating [ ] just my romantic partner [ ] currently sexually satisfied [ ] terminated pregnancy [ ] living companions dysfunctional [ ] friends have similar prob s [ ] currently sexually dissatisfied [ ] age at first pregnancy/fatherhood [ ] drinking/drugs used in the home [ ] sexually transmitted disease [ ] history of miscarriage Additional information:
7 ADULT PSYCHOLOGICAL HISTORY Name: Page 7 Employment: Military history: Cultural/spiritual/recreational history: [ ] employed and satisfied [ ] never in military [ ] employed and unsatisfied [ ] military Hon. Discharge Cultural identity? (ethnicity, religion): [ ] unemployed now [ ] military other Discharge Community/Recreational activities? Y N [ ] often unemployed [ ] discipline problems [ ] coworker conflicts [ ] problems after discharge Still Participate? Y N [ ] supervisor conflicts [ ] Post-Traumatic Stress [ ] lost several jobs [ ] disabled Legal history: Financial situation: [ ] no legal problems [ ] now on parole/probation [ ] arrested as juvenile [ ] court ordered this treatment/evaluation [ ] no current financial problems [ ] arrested as adult [ ] poverty or below-poverty income [ ] spent time in jail [ ] total time served: [ ] lots of debts [ ] impulsive spending Describe any current legal difficulty: [ ] relationship conflicts over finances PERSONAL INSIGHT Strengths: Weaknesses: What I Need To Work On: Please complete the following sentences: I feel angry/ resentful because I am afraid of I feel hopeless about
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