Adult History Form
Patient's name: ______________________
How did you get here today? Bus / Taxi / Walked / Drove Myself /
Driven by _________________
Person completing form (relationship to the patient):
Self/Mother/Father/Son/Daughter/Interpreter/Spouse
Problems
Check any mental or emotional problems which you have:
_____ Learning problems (needed special classes in school, learning
disabilities, slow learner, brain damage)
_____ Depression (often feeling very sad)
_____ Anxiety (often feeling very nervous)
_____ Hallucinations (hearing voices or seeing things that others don't
_____ Trouble concentrating
_____ Can't get along with other people
_____ Violent behavior
_____ Drink too much alcohol
_____ Use illicit drugs (marijuana, heroin, cocaine, etc.)
_____ Memory problems
_____ Other: ______________________________________________
Check any problems below that apply to you:
___ Autism ___ Seizure Disorder ___ Mental Retardation___ Bipolar (Manic Depressive)
___ Speech Problems ___ Schizophrenia ___ Brain Tumor ___ Stroke
___ Heart Attack ___ Brain injury ___ Lost consciousness ___ War or violent crime
experience
Family History:
Marital Status: Married / Divorced / Never Married / Widowed
How many times have you been married? _____
How many children do you have? _____ Children's ages? ___
Whom do you live with? ___________________________________
If divorced, when (your age or the year)? ________________
If widowed, when? _________________
Check any statement that applies:
_____ My father died when I was _____
_____ My mother died when I was _____
_____ My parents separated or divorced when I was _____
_____ I was raised by both parents.
Where do you live? House/ApartmentGroup
Home/Hotel/Homeless/Other
Where were you born? City __________ Country __________
If you were born outside the USA, when did you come to this country?
_________
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Educational History
Circle the last grade you completed: 1 2 3 4 5 6 7 8 9 10 11 12
Educational degrees: HS Grad/GED/Assoc./Bach./Masters/Doct.
College (number of years): _____
Were you in special education classes? Yes No
What was your grade average in high school? A B C D F
What language do you speak best? _____________________
Vocational History
What types of work have you done (i.e., labor, cashiering, gardening,
teaching, construction, etc.):
___________________________________________________
What was the longest time you stayed at a job? ___________
What did you do on your last job? ________________________
When did you last work? ___________
Why did your last job end? _______________________________
Medical History:
List any medical (not psychiatric or behavioral) problems which you
have been diagnosed with:
List all medications which you currently take:
Medication Dose (m.g.) Times per day For what problem?
Have you ever had surgery? List your age when you had surgery and
the reason below.
Have you ever been hospitalized overnight for medical reasons other
than surgery? List your age when you were hospitalized and the reason.
Age: Reason:
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Mental Health History:
Have you ever been placed in a psychiatric hospital? List your age
when you were hospitalized and the reason.
Age: Reason:
Have you ever seen a counselor, psychologist, or psychiatrist?
Age when you How long did Reason you Type of therapist
Attended Sessions you attend? attended? (PhD, MD, School)
Has a doctor ever prescribed medication to you to help with
depression, anxiety, behavior, or mental problems (such as Ritalin,
antidepressants, etc.)
Age when medication To help with Type of
was prescribed? what problem? medication?
Did you ever attempt suicide? Yes No
If yes, how many times? _____
When was the first time? __________
When was the last time? ___________
How did you try to do it? __________________________________
Legal problems
How many times have you been arrested or charged with a crime?
Never 1 2 3 4 5 or more
If yes, what crimes have you been charged with? __________
__________________________________________________________
How old were you the first time you were in trouble with the law?
_______
When were you last charged with a crime? __________
Have you ever been in jail or prison? Yes No
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Alcohol and Drugs
How often do you drink alcohol? Every day/Few times a week/
Few times a month/
Once a month or less/Never
Has drinking alcohol ever caused problems for you
(other people tell you to drink less, legal problems,
relationship problems)? Yes No
If yes, at what age did alcohol start to cause problems? _____
When did you have your last drink? ____________
Have you ever used illicit drugs? Yes No
If yes, which ones? Marijuana Cocaine PCP Heroin LSD
Amphetamines Barbituates Sniff glue/paint
Other _______________
When did you last use a drug? __________
How old were you when you first used a drug? __________
Daily Functioning
Driving: Check the one which applies:
_____ I have never driven a car
_____ I still drive
_____ I used to drive a car but haven't since: ______________________
Are you able to shower, bathe, and groom yourself without help? Yes No
Are you able to get dressed by yourself? Yes No
Are you able to pay bills, and keep track of money without help from other
people? Yes No
Describe what you do in a typical day: