Life History Questionnaire- Adults Today's Date: Name: Gender and Pronouns: Date of Birth: Age: Address: Phone Number: Emergency Contact Name and Phone: Referred by: (1) Please state the reason that you are seeking psychiatric evaluation. What is the problem(s)? When did the problem(s) begin? What has been done to try to alleviate the problem(s)?* When was the last time you felt both physically and emotionally well for a sustained period of time? (2) Have you been previously evaluated by a psychiatrist or other mental health professional? If so, please describe:(3) Have you received any previous treatment, including therapy, counseling, or medication, for the treatment of emotional, behavioral, or learning problems? If so, please describe:(4) Have you ever been hospitalized for psychiatric treatment? If so, please describe: ** Please bring to the first appointment the names, addresses, and phone numbers of the individuals, clinics, or hospitals where previous treatment has taken place.Substance History: Please describe use of alcohol, caffeine, tobacco, drugs (i.e. marijuana, cocaine, heroin, ecstasy, PCP, amphetamines, pain medication, etc…). Include date of last use or if currently using.Have you required treatment for misuse, abuse, and/or dependence of any substance?: (5) Medical History- Please indicate if you have suffered from any of the following medical problems: Head Injury Seizure Recurrent Headaches Recurrent stomachaches or digestive problems Asthma Diabetes Anemia Kidney disease Liver disease Heart disease Hearing impairment Glaucoma Thyroid disease Other Other medical problems: Please describe any of the above:Have you ever been hospitalized for medical illness? If so, dates, hospital, and reason?Do you have any allergies? Please describe: Do you currently take medication? Please include over-the-counter medications such as cold or allergy preparations, as well as any herbal or naturopathic medicines):Date of Last Physical Exam: Name, Address, and Phone Number of Primary Care Physician Please check any of the following that applied to your childhood: Hyperactivity Attention Problems Fears/worries Learning difficulties Night terrors Physical abuse Emotional Abuse Sexual Abuse Unhappy childhood Age Beginning School: Age Finishing School: Highest Degree Acquired: 6) Social/Environmental- Biological Parents are: Married and living together Unmarried and living together Unmarried, not living together Divorced Separated Mother deceased Father deceased Unknown If biological or adoptive parents are divorced, date divorced: Family members in household: (name, age, relationship) Add RemoveDo any family or household members currently suffer from significant physical health problems? If yes, please describe: Do any family members or household members currently suffer from significant mental or emotional health problems? If yes, please describe: Are there currently or have there been any significant marital problems? If yes, please describe: Are there currently any significant stressors affecting your family life? If yes, please describe: What is your current occupation?: How is most of your free time occupied?: What are your interests, hobbies, activities?: If known, has your biological father or have any of his family members had any of the following problems? Depression Anxiety Bipolar disorder Obsessive/Compulsive disorder Schizophrenia Alcohol abuse Drug abuse Learning problems Attention Deficit/Hyperactivity Disorder Psychiatric hospitalization Mental retardation Autism-related disorder Criminal behavior Suicide attempt / completed suicide If any checked, please describe: * If you know the medication used for a condition listed above, please note med name, if it was helpful, or if there was an adverse effect / side effect. If known, has your biological mother or have any of her family members had any of the following problems? Depression Anxiety Bipolar disorder Obsessive/Compulsive disorder Schizophrenia Alcohol abuse Drug abuse Learning problems Attention Deficit/Hyperactivity Disorder Psychiatric hospitalization Mental retardation Autism-related disorder Criminal behavior Suicide attempt or completed suicide If any checked, please describe: * If you know the medication used for a condition listed above, please note med name, if it was helpful, or if there was an adverse effect / side effect. (10) Please provide any additional information that you believe might be helpful in understanding the problem you are having:
