Penfield Psychiatry
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Mental Health Assistant
Psychological/Neuropsychrological Testing Services Adult History
Patient's full Name
*
Date
MM slash DD slash YYYY
Age
*
Please enter a number from
1
to
99
.
Birth Date
*
MM slash DD slash YYYY
Sex
Male
Female
Other
Education
Ethnic/Racial Background
Primary Language
Secondary Language
Hand used for writing
Right
Left
Current problem areas / areas of concern
Early History
You were born:
On Time
Prematurely
Late
Were there any problems associated with your birth (e.g., oxygen deprivation, unusual birth position, etc.) or the period immediately afterward (e.g., underweight, need for oxygen, special equipment used, convulsions, illnesses, etc.)?
Yes
No
If yes, please describe
Check any and all that applied to your mother while she was pregnant with you:
Accident
Psychological Problems
Alcohol Use
Drug Use (marijuana, speed, cocaine, LSD, etc.)
Cigarette Smoking
Poor Nutrition
Illness (toxemia, diabetes, high blood pressure, infection, RH incompatibility, etc.)
Other
Other problems (list)
As a child, did you have any of these conditions? (Check all that apply)
Attention Problems
Head Injury
Muscle Tightness or Weakness
Clumsiness
Hearing Problems
Speech Problems
Frequent Ear Infections
Learning Disability
Behavior Issues
Other problems
Other :
Were you ever tested for developmental disabilities (e.g., cerebral palsy, specific learning disabilities, autism, ADHD, etc.)?
Yes
No
MEDICAL HISTORY:
Please list past and current medical conditions
Has you ever been hospitalized before?
Yes
No
Describe:
Has you ever suffered a serious injury to your head?
Yes
No
Describe head injury
Please note all medications taken at present, their dosage, and frequency given. Example: Depakote 100 mg. 2 tablets/ AM, 1.5 tablets/ afternoon, 4 tablets/ evening.
FAMILY HISTORY:
Please check all that existed in close biological family members (parents, brothers, sisters, grandparents, aunts, uncles), note who it was, and describe the problem indicated:
Neurological/Brain condition
Who
Describe
Learning Disability
Who
Describe
Mental Retardation
Who
Describe
ADHD
Who
Describe
Alcohol/Drug Dependency
Who
Describe
Bipolar Disorder
Who
Describe
Depression
Who
Describe
Personality Disorder
Who
Describe
Schizophrenia
Who
Describe
Other Psychiatric Illness
Who
Describe
Other Disease/ Disorder
Who
Describe
PSYCHOSOCIAL HISTORY:
Current marital status
Married
Single
Divorced
Separated
Widowed
Years married to current spouse
Please enter a number from
0
to
99
.
Number of times married
Please enter a number from
0
to
20
.
Do you have children
Yes
No
Please list child(ren)'s name(s), age(s), and sex
Who do you currently live with (list)
Would you consider the current living situation/environment stressful?
Yes
No
Maybe
What is your best attribute/characteristic (e.g. , friendly, hard worker)?
What is your worst attribute/characteristic (e.g. , stubborn, quick tempered)?
Describe any organizations, volunteering, hobbies, reading interests, or other leisure-time activities in which you currently engage in:
Has you ever been under the care of a psychiatrist, psychologist, or counselor?
Yes
No
If Yes, what were you seen for?
Are you currently under the care of:
psychiatrist
psychologist/counselor
LEGAL
Have you ever been arrested?
Yes
No
If yes, please explain
In the past 5 years have you incurred any moving traffic violations? (e.g., speeding, DWI, DWAI)
Yes
No
If yes, approximately how many?
Please enter a number from
0
to
20
.
EDUCATIONAL HISTORY:
Number of years of formal education completed
Did you receive a
Diploma
G.E.D.
Neither
If diploma, please indicate degree (e.g., R.S., H.S., B.A., M.A., J.D., M.D., Ph.D.):
How would you describe your usual performance as a student?
A & B
B & C
C & D
D & F
Please provide any additional helpful comments about your academic performance:
Were you ever held back a grade?
Yes
No
Were you ever in any special class(es) or received special education services (IEP/504 plan)?
Yes
No
If yes, what grade?
OCCUPATIONAL HISTORY:
Are you currently employed?
Yes
No
Current job title
How long have/had you been on this job?
Please give a brief description of your responsibilities:
Please list all of the types of jobs you have had in the past:
Have you been in the military?
Yes
No
SUBSTANCE USE HISTORY:
I drink alcohol:
Rarely or never
1 – 2 days per week
3 – 5 days per week
daily
I used to drink but stopped on (date):
MM slash DD slash YYYY
I started drinking regularly at age
less than 10 years old
age 10-15
age 16-18
age 19-21
over 21
Preferred type(s) of drinks
Usual number of drinks I have at a time
Please enter a number from
1
to
99
.
My last drink was:
less than 24 hours ago
24 to 48 hours ago
over 48 hours ago
Check all that apply:
I can drink more than most people my age and size before I get drunk.
I sometimes get into trouble (e.g., fights, legal difficulty, problems at work, conflicts with my family, accidents) after drinking.
I sometimes blackout after drinking.
I have gone through alcohol withdrawal.
Please check all the drugs you are now using or have used in the past:
Alcohol
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Tobacco
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Caffeine
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Amphetamines (including diet pills)
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Barbiturates (downers)
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Cocaine or crack
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Hallucinogens/ LSD
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Inhalants (glue, spray cans, etc.)
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Marijuana
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Opiate narcotics
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
PCP (angel dust)
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Other drugs
Not using
Presently using
Used in the past
(drug name)
Date
MM slash DD slash YYYY
Δ
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