Confidential Patient Information
Complete all sections
A. PATIENT INFORMATION
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Info
*
What is the best number to reach you?
*
Please Select
Home
Work
Cell
Additional Info
*
Sex
FEMALE
MALE
Marital Status
Please Select
married
single
divorced
separated
widowed
other
Handedness
Please Select
right handed
left handed
mixed
Level of Education Completed
Please Select
9th
10th
11th
12th no diploma
High School Graduate
GED
Some college
Associates
Bachelors
Masters
Professional school degree
Doctoral degree
Refuse
Don't know
Majors
Any difficulties (behavioral/academic) while in school
YES
NO
Ever been diagnosed with a learning disability?
YES
NO
Employment
Disabled
YES
NO
Retired
YES
NO
Annual Income
B. REFERRAL INFORMATION
Who referred you?
*
Reason for referral
*
Were you injured on the job (Workman's Comp)?
*
YES
NO
Are you represented by an attorney?
*
YES
NO
Describe the problems you've been having and for how long?
*
What do you hope to learn from this visit/or evaluation?
*
C. MEDICAL HISTORY
Do you have any medical conditions?
*
e.g. high blood pressure, cancer, diabetes, etc.
Check all that apply
*
Have you ever had meningitis?
Have you ever had Scarlett Fever?
Have you been exposed to toxins such as lead, solvents?
Do you have any hearing or vision problems?
Do you wear glasses or hearing aids?
Any family history of medical or neurological conditions (e.g. Alzheimer, Parkinson's, stroke)?
Have you ever been in a motor vehicle/motorcycle accident or had a fall?
Ever had seizures or convulsions?
Ever had a stroke?
Ever had dizziness?
Migraine headaches?
Nausea?
None
Have you ever had a head injury?
*
YES
NO
If YES, did you lose consciousness or black out?
YES
NO
If YES, answer the following:
Do you take any medications?
*
YES
NO
If YES please list ALL Medications
D. PSYCHIATRIC/EMOTIONAL HISTORY
Check all that apply
*
Ever seen a mental health worker (psychologist, psychiatrist, counselor)?
Ever been hospitalized for emotional problems?
Ever attempted suicide?
Are you currently taking any medications for emotional problems?
Any family history of psychiatric hospitalizations?
Any family history of suicide?
None
E. DRUG/ALCOHOL USE
Do you drink alcohol?
YES
NO
Do you use illicit drugs?
YES
NO
If YES, name and time.
Any family history of alcohol or drug use?
YES
NO
F. HISTORY OF LEGAL PROBLEMS OR ARRESTS
Have you ever been arrested?
YES
NO
If YES, please explain
Signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
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