adult history (this information will be included … history (this information will be included in...

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ADULT HISTORY

(This information will be included in the final report)

Patient’s Name: _________________________________________ Age: _______ Date of Birth: ________________

Sex: _____ Education: __________ Primary Language: ______________ Secondary Language: _____________

Ethnicity Origin (Optional): Mark all that apply.

American Indian Asian Black or African American Hispanic or Latino

Native Hawaiian or other Pacific Islander White/Caucasian Other

Who is your primary care physician? _________________________________________________________________

Medical diagnoses (if any): (1) ______________________________________________________________________

(2)____________________________________________ (3) _______________________________________________

Who referred you for this evaluation: _________________________________________________________________

Briefly describe problem(s):

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

When did the problem(s) begin? ______________________________________________________________________

If an accident occurred, what was the date of the accident? _______________________________________________

What specific questions would you like answered by this evaluation?

(1) ______________________________________________________________________________________________

(2) ______________________________________________________________________________________________

3) ______________________________________________________________________________________________

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SYMPTOM SURVEY

For each symptom that applies, place a check mark on the line. Add any helpful comments next to the line.

1) PROBLEM SOLVING Date of Onset

Difficulty figuring out how to do new things ____________

Difficulty planning ahead ____________

Difficulty figuring out problems that most other people can do ____________

Difficulty thinking as quickly as needed ____________

Difficulty doing things in the right order (sequence problems) ____________

Difficulty verbally describing the steps in doing something ____________

Difficulty changing a plan or activity when necessary ____________

Difficulty completing an activity in a reasonable amount of time ____________

Difficulty doing more than one thing at a time ____________

Difficulty switching from one activity to another activity ____________

Impulsivity ____________

Easily frustrated ____________

Other problem solving difficulties: ________________________________ ____________

2) SPEECH, LANGUAGE, AND MATH SKILLS Date of Onset

Difficulty finding the right word to say ____________

Difficulty understanding what others are saying ____________

Unable to speak ____________

Difficulty staying with one idea ____________

Difficulty writing letters or words (not due to motor problems) ____________

Slurred speech ____________

Odd or unusual speech sounds ____________

Difficulty with math (e.g., checkbook balancing, making change) ____________

Difficulty understanding what I read ____________

Difficulty speaking ____________

Other speech, language, or math problems: __________________________ ____________


3) NONVERBAL SKILLS Date of Onset

Difficulty telling right from left ____________

Difficulty doing things I should automatically be able to do ____________

(e.g., brushing teeth, etc.)

Difficulty drawing or copying ____________

Difficulty dressing (not due to physical difficulty) ____________

Difficulty finding my way around places I’ve been to before ____________

Difficulty recognizing objects or people ____________

Parts of my body do not seem as if they belong to me ____________

Unaware of things on one side of my body: Right Left ____________

Decline in my musical abilities ____________

Not aware of time (e.g., time of day, season, year) ____________

Slow reaction time ____________

Other nonverbal problems: ______________________________________ ____________

4) CONCENTRATION AND AWARENESS Date of Onset

Highly distractible ____________

Difficulty focusing ____________

Lose my train of thought easily ____________

Difficulty finishing what I start ____________

Become easily confused and disoriented ____________

Blackout spells (fainting) ____________

My mind goes blank ____________

Aura (strange feelings) ____________

Don’t feel very alert or aware of things ____________

Motor restlessness (e.g., foot tapping, difficulty sitting still) ____________

Other concentration or awareness problems: _________________________ ____________


5) MEMORY Date of Onset

Forgetting where I leave things (e.g., keys, gloves, etc.) ____________

Forgetting names ____________

Forgetting what I should be doing ____________

Forgetting where I am or what I am doing ____________

Forgetting events that happened quite recently (e.g., last meal) ____________

Need someone to give me a hint so I can remember things ____________

Relying more and more on notes to remember things ____________

Forgetting the order of things (e.g., when cooking, etc.) ____________

Forgetting facts, but I can remember how to do things ____________

Forgetting how to do things, but I can remember facts ____________

Forgetting faces of people I know (when they are not present) ____________

Frequently forgetting appointments ____________

Other memory problems: ________________________________________ ____________

6) MOTOR AND COORDINATION Check the side this occurs on: Date of Onset

Right Left Both

Fine motor control problems ____________

(using a key, pencil, etc.)

Weakness on one side of my body ____________

Difficulty holding onto things ____________

Tremor or shakiness ____________

Muscle tics or strange movements ____________

My writing is very small ____________

My writing is very large ____________

Walking more slowly than other people ____________

Feeling stiff ____________

Recent Falls ____________

Balance problems ____________

Difficulty starting to move ____________

Jerky muscles ____________

Muscles tire quickly ____________

Often bumping into things ____________


Other motor or coordination problems: ______________________________ ____________

7) SENSORY Check the side this occurs on: Date of Onset

Right Left Both

Loss of feeling or numbness ____________

Tingling or strange skin sensations ____________

Difficulty telling hot from cold ____________

Problems seeing on one side ____________

Blurred vision ____________

Blank spots in vision ____________

Brief periods of blindness ____________

See “stars” or flashes of light ____________

Double vision ____________

Difficulty looking quickly from one object to another object ____________

Need to squint or move closer to see clearly ____________

Losing hearing ____________

Ringing in my ears or hearing strange sounds ____________

Difficulty tasting food ____________

Difficulty smelling ____________

Smelling strange odors ____________

Other sensory problems: _________________________________________ ____________

8) PHYSICAL Date of Onset

Headaches ____________

Dizziness ____________

Nausea or vomiting ____________

Urinary incontinence ____________

Loss of bowel control ____________

Excessive tiredness ____________

Sensitivity to bright lights ____________

Sensitivity to loud noises ____________

Sleep Disorder ____________

Who diagnosed your sleeping disorder? __________________________________________


Current Treatment? __________________________________________________________

Other physical problems: ________________________________________ ____________

9) BEHAVIOR Check all that apply to you in the past 6 months: Date of Onset

Rate Severity: Mild Moderate Severe

Sadness or depression ____________

Anxiety or nervousness ____________

Stress ____________

Sleeping Problems ____________

Become angry more easily ____________

Euphoria (feeling on top of the world) ____________

Much more emotional (e.g., cry more easily) ____________

Feel as if I just don’t care anymore ____________

Doing things automatically (without awareness) ____________

Less inhibited (do things I would not do before) ____________

Difficulty being spontaneous ____________

Change in eating habits: _________________________________________ ____________

Increase in weight: _________ Decrease in weight: _________ ____________

Change in interest in sex: ________________________________________ ____________

Change in energy level ____________

Experience nightmares on a daily/weekly basis ____________

Lack of interest in pleasurable activities ____________

Increase in irritability ____________

Increase in aggression ____________

Other recent changes in behavior or personality: ______________________ ____________

Overall, my symptoms have developed: Slowly Quickly

My symptoms occur: Occasionally Often

Over the past 6 months my symptoms have: Stayed the same Worsened Improved

In summary, there is: Definitely something wrong with me

Possibly something wrong with me

Nothing wrong with me


EARLY HISTORY

(Complete all that you can for this section)

You were born: On time Prematurely Late

Your weight at birth: ________ lbs. ________ oz.

Were there any problems associated with your birth (e.g., oxygen deprivation, unusual birth positions, etc.) or the period immediately afterward (e.g., need for oxygen, special equipment used, convulsions, illness, etc.)?

Yes No Describe: _________________________________________________________________________

Check all that applied to your mother while she was pregnant with you:

Accident (describe): ______________________________________________________________________________

Alcohol use

Cigarette smoking

Drug use (marijuana, speed, cocaine, LSD, etc.)

Illness (toxemia, diabetes, high blood pressure, infection, RH incompatibility, etc.)

Poor nutrition

Psychological problems

Other problems: _________________________________________________________________________________

List all medications (prescribed or over-the-counter) your mother took while pregnant:

__________________________________________________________________________________________________

During her pregnancy, did your mother live near a polluted area (e.g., toxic waste dump) or other hazardous area (nuclear plant, industrial area, pesticide sprayed area, etc.)?

Yes No Describe: _________________________________________________________________________

Rate your developmental progress as it has been reported to you, by checking one description for each area:

Early Average Late

Walking

Language

Toilet training

Overall development


As a child, did you have any of these conditions: (Check all that apply)

Attentional problems Head injury Depression

Clumsiness Hearing problems Vision problems

Developmental delay Hyperactivity Loss of consciousness

Learning disability Frequent ear infection Muscle tightness or weakness

Speech problems

Other psychiatric difficulty: ________________________________________________________________________

Other problems: _________________________________________________________________________________

MEDICAL HISTORY

CHILDHOOD MEDICAL HISTORY

Check all the conditions that were diagnosed when you were a child. Add any helpful details (age at diagnosis, treatment provided, etc.):

Concussion Epilepsy or seizures Pneumonia

Scarlet fever Fevers (104°F or higher) Poisoning

Brain infection or disease Heart problems Polio

Rheumatic fever Immune system disease Cancer

Cerebral palsy Kidney problems Asthma

Chicken pox Lung (respiratory problems) Diabetes

Colds (excessive) Venereal disease Measles

Oxygen deprivation Whooping cough Meningitis

Tuberculosis Encephalitis Allergies

AD/HD or ADD Learning difficulties/disability

Other disease or disabilities: _______________________________________________________________________

As a child, were you exposed to excessive amounts of lead (e.g., eating paint chips, living next to high concentration of automobile exhaust fumes, etc.)? Yes No

If yes, explain: _____________________________________________________________________________________

As a child, did you have an accident that required a hospital visit? Yes No

If yes, explain: _____________________________________________________________________________________

Did you ever suffer a serious injury to your head? Yes No


Was there loss of consciousness? Yes No If so, for how long? ____________________________________

If yes, explain the circumstances and any problems you had afterwards:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

How would you describe your nutrition as a child and adolescent? Excellent Average Poor

List the medications that were regularly given to you as a child:

Medication Reason for Medication

______________________________________ __________________________________________________________

______________________________________ __________________________________________________________

ADULT MEDICAL HISTORY (Check all that apply)

AIDS or HIV+ Heart disease

Allergies Huntington’s disease

Ateriosclerosis (artery disease) Hypertension

Arthritis Kidney disease

Blood disorder Loss of consciousness

Brain disease or infection Lung (respiratory) disease

Cancer or chemotherapy Malnutrition

Parkinson’s disease Meningitis

Psychiatric problems Multiple Sclerosis

Dementia Polio

Venereal disease Radiation exposure or therapy

Hazardous substance exposure Thyroid disease

Concussion Head injury

Any other problems: ______________________________________________________________________________

List any medications you currently take (prescribed or over-the-counter) and dosage:

__________________________________________________________________________________________________

__________________________________________________________________________________________________


Do you have epilepsy or a seizure disorder? Yes No

What Type? _______________________________________________________________________________________

Partial Generalized Unclassified

I have a seizure disorder but don’t know which type. Please describe it:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Are you currently in psychotherapy, counseling, or under psychiatric care? Yes No

Have you ever been in psychotherapy, counseling, or under psychiatric care? Yes No

If yes, when and with whom?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Have you ever been prescribed psychotropic medication (e.g., antidepressant, anti-anxiety, tranquilizer)?

Yes No If yes, what?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

List all inpatient mental health hospitalizations including the name of the hospital, dates of hospitalization, duration, and

diagnosis.

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________


MEDICAL TESTING

Check all the medical tests that recently have been done and report any abnormal findings:

Check if normal Abnormal findings

Angiography ____________________________________________________

Blood Work ____________________________________________________

Brain SPECT ____________________________________________________

CT Scan of head ____________________________________________________

MRI ____________________________________________________

PET scan ____________________________________________________

EEG ____________________________________________________

Lumbar puncture ____________________________________________________

Neurological Exam ____________________________________________________

Physician’s Office Exam ____________________________________________________

Ultrasound ____________________________________________________

Other: ____________________ ____________________________________________________

Date of last vision and hearing exam? _________________________________________________________________

Have you had a prior psychological or neuropsychological evaluation? Yes No

If yes, who was the psychologist? ____________________________________ Date of evaluation: ________________

Findings of evaluation:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________


SUBSTANCE USE HISTORY

ALCOHOL USE

I began drinking alcohol regularly at age: Prior to age 10 10-15 16-18 19-21 over 21

I drink alcohol: rarely or never 1-2 days/week 3-5 days/week daily

I used to drink alcohol but have stopped. Date stopped: ___________________

Preferred types of alcoholic drinks: _____________________________________________________________________

Usual number of drinks I have at one time: _______________________________________________________________

My last drink was: less than 24 hours ago 24-48 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 problems, conflicts, problems at work, accidents, etc.) after drinking

I sometimes black out after drinking

DRUG USE

Please check all the drugs you are now using or have used in the past:

Presently using Used in past

Amphetamines (including diet pills)

Barbiturates (downers, etc.)

Cocaine or crack

Hallucinogenics (LSD, acid, STP, etc.)

Inhalants (glue, nitrous oxide, etc.)

Marijuana

Opiate Narcotics (heroin, morphine, etc.)

PCP (angel dust)

Other recreational drugs: __________________________________________________________________________

Do you consider yourself dependent on any of the above substances? Yes No

Do you consider yourself dependent on any prescription drugs? Yes No


Check all that apply:

I have gone through drug withdrawal

I have used I.V. drugs

I have been in drug/alcohol treatment Date/Location: _________________________________________________

Have you ever used tobacco? Yes No

If you currently use tobacco, what is the amount per day? _____________ Date Quit:___________________________

Do you drink caffeinated beverages? Yes No Amount per day: ____________

LEGAL/CRIMINAL HISTORY

Describe any history of arrests, charges, convictions:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Are you currently in litigation? Yes No If so, is it related to this evaluation/injury? Yes No

FAMILY HISTORY

The following questions deal with your biological family members.

MOTHER

Is she alive? Yes No If deceased, what was the cause of death? ____________________________________

Mother’s occupation: __________________________ Mother’s highest level of education: ____________________

Does/did your mother have a known or suspected learning difficulty? Yes No

If yes, describe: ____________________________________________________________________________________

FATHER

Is he alive? Yes No If deceased, what was the cause of death? ____________________________________

Father’s occupation: __________________________ Father’s highest level of education: ____________________

Does/did your father have a known or suspected learning difficulty? Yes No

If yes, describe: ____________________________________________________________________________________


SIBLINGS

How many siblings do you have? __________ What are their ages? ______________________________________

Are there any problems (physical, academic, psychological) associated with any of your siblings?

Yes No If yes, describe:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

CHILDREN

How many children do you have? Girls Ages: _________________________________________________

Boys Ages: _________________________________________________

Are there any problems (physical, learning, behavior, psychological) associated with any of your children?

Yes No If yes, describe :

__________________________________________________________________________________________________

__________________________________________________________________________________________________

MARITAL STATUS

Marital status: Single Partnered Married Divorced Widowed

How many times have you been married? _____________

Spouse’s age: __________ Spouse’s occupation: ________________________________________________________

How is your spouse’s health? Excellent Average Poor

EDUCATIONAL HISTORY

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:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Highest grade or degree you’ve earned: _______________________________________________________________


What was your best subject(s)? _______________________________________________________________________

What was your weakest subject(s)? ___________________________________________________________________

Were you ever held back to repeat a grade? Yes No

If yes, what grade? ________________________ Or age? __________________________

Were you ever in any special class(es) or did you receive special education services?

Yes No If yes, what grade: __________ Or age? __________

What type of class? _________________________________________________________________________________

OCCUPATIONAL HISTORY

Current job title: _________________________________________________ Years in this position: ______________

Salary: Under $10,000 10,000 – $29,900 $30,000 – $50,000 Over $50,000

Current job responsibilities: _________________________________________________________________________

History of shift work? Yes No

Prior jobs (start with most recent):

__________________________________________________________________________________________________

__________________________________________________________________________________________________

At any time on a job, were you exposed to toxic, hazardous, noxious, or otherwise dangerous or unusual substances (e.g., lead, mercury, radiation, solvents, pesticides, chemicals, etc.)? Yes No

If yes, explain: _____________________________________________________________________________________

MILITARY HISTORY

Branch: ________________________________________ Discharge Rank: _________________________________

Type of Discharge: _________________________________________________________________________________

Major military duties: ______________________________________________________________________________

Did you sustain any physical injuries in the military? Yes No

If yes, describe: ____________________________________________________________________________________


Were you ever exposed to any dangerous or unusual substances during your service?

Yes No If yes, explain: __________________________________________________________________

RECREATION

Briefly list the types of recreation you enjoy:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

OTHER INFORMATION

Please provide other information you think may be important:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Thank you for taking the time to carefully complete this questionnaire.

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