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MEDICAL AND PERSONAL HISTORY (ADULT)
Thank you for taking the time to answer these questions. Your completing this form makes it possible for us to have more time to talk during the initial session. Please indicate if you have or have had any of these symptoms now or in the last few weeks: ___ Fatigue or low energy ___ Depressed mood, feeling down or blue most of the time ___ Not enjoying things you usually enjoy ___ Feeling slowed down or very sluggish ___ Feeling nervous, agitated, or antsy ___ Feeling worthless or guilty ___ Can’t concentrate or pay attention ___ Can’t make decisions ___ Poor self-esteem ___ Irritable, cranky, out-of-sorts ___ Crying spells ___ Not interested in sex or other sexual issues ___ Drinking more alcohol than usual ___ Feeling anxious most of the day ___ Frequent thoughts of death or dying ___ Excessive worrying ___ Feeling like life is not worth living ___ Panic episodes (e.g., palpitations, sweating, shaking, shortness of breath, nausea or dizziness, feeling that the world is coming to an end) ___ Don’t want to leave the house or go out in public ___ Increase in aches and pains (headaches, stomach distress, etc.) ___ Repetitive thoughts that you can’t get out of your mind Sleep disturbance: ___ Waking up early in the morning and can’t get back to sleep ___ Frequent nausea or gastrointestinal distress ___ Weight change in last month: _______________ ___ Other troublesome symptoms. Please specify: _____________________________ _______________________________________________________________________ _______________________________________________________________________ Please list any health problems that you have (for example, allergies, migraines, diabetes, arthritis, high blood pressure, etc.): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please list any medications that you take (include prescription medication and over-the-counter medication such as aspirin or Pepcid as well as any herbal or homeopathic preparations): Have you ever had any allergic reactions to any medicinal agents? Yes No When was your last physical exam and by whom was it conducted? _________________ Does anyone in your family (parents, grandparents, siblings) have a history of any of the following? Please specify who had the problem. Problem Depression _____________________________ ___ Bipolar disorder (“manic-depressive”) _____________________________ ___ ___ Anorexia/bulimia/other eating disorder _____________________________ ___ Attempted suicide (tried but lived) How many drinks per day? _________________ Do you use alcohol? Yes No How many drinks per week? _______________ Do you smoke cigarettes? Yes No How many packs per day? _________________ Do you use other tobacco products? Yes No How often?__________________ Have you ever had any psychological counseling/therapy/evaluation in the past? Yes No Please indicate when and for what purpose: _____________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Did you find this helpful? ___________________________________________ _______________________________________________________________________ PERSONAL HISTORY: Mother’s occupation: _____________________________________________________ Mother’s current age or date of death: __________________________________ Father’s occupation: ______________________________________________________ Father’s current age or date of death: ___________________________________ Who reared you if you were not reared by your biological or adoptive parents? ________ ________________________________________________________________________ You highest level of education: _____________________________________________ Your current occupation: __________________________________________________ Religious preference, if any: ________________________________________________ Are you married or partnered? Yes No Spouse/partner’s first name and occupation: ___________________________________ First names and ages of children: ____________________________________________ __________________________________________________________________ EMERGENCY CONTACT: In the event of an emergency, whom should we contact? Name: ________________________________________________________________ Address: _______________________________________________________________ Relationship to you: ______________________________________________________ Phone numbers: Home _____________________ Business _____________________

Source: http://www.csidurham.com/index%20webpage%209-20_files/pdfs/Adult%20Medical%20History%20Form%202009.pdf