Background History Form

Background History Form
Form Name
Today's Date*

MonthDayYear
Date
We have learned that it is hard to remember everything you want to tell us when you are sitting in our office. We want to know as much as we can about your concerns and living circumstances, and have found that asking many of our questions ahead of your visit makes it easier for everyone involved. Please answer the following questions to the best of your ability. Some of the items will probably not apply to your situation, however we live in diverse world and hope to not overlook possibilities. The more you tell us, the better the job we can do to address your concerns. If a section of the questionnaire doesn’t apply to you (for example occupational history for a child), or if you prefer to not answer any questions that's ok - just skip to the next one!
PATIENT/PRIMARY CLIENT'S INFORMATION
Patient Name*
Date of Birth*

MonthDayYear
Date
Gender
Pronouns
Race/Ethnicity
Language(s) Spoken
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Phone Type
Phone Number
Please enter a valid phone number.
Phone Type
Please provide us with appropriate email addresses- we will never share them with others without your permission

	Name	Relationship	Email
Person 1
Person 2
Person 3
Person 4

INFORMATION REGARDING IMPORTANT PERSONS IN THE PRIMARY PATIENT'S LIFE
Please provide us with additional contact information of important persons in the primary patient's life - we will never share them with others without your permission
Important Person #1*
Contact Phone Number*
Please enter a valid phone number.
Relationship*

ParentSpouse/PartnerGuardianOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Important Person #2
Contact Phone Number
Please enter a valid phone number.
Relationship

ParentSpouse/PartnerGuardianOther
Same as patient address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PLEASE LIST YOUR CONCERNS AND REASONS FOR SEEKING SERVICES
Please list your specific concerns and reasons for seeking services*
Please tell us specifically what you would like to have happen in coming to our office
Looking for consultation/advice/education
Looking for an evaluation
Please Explain (Consultation)
Please Explain (Evaluation)
Looking for individual therapy/counseling
Looking for family therapy/counseling
Please Explain (Individual Therapy)
Please Explain (Family Therapy)
Looking for referral
Other
Please Explain (Referral)
Please Explain (Other)

	Score
1 minute
5 minutes
10 minutes

	Ages for:
Sitting
Crawling
Walking
Well-coordinated
Self-feeding
Scribbling
Tied shoes
Babbling
First words
Sentences
Good use of language
Toileting during the day
Toileting at night

PARENTS HISTORY

Complete those that apply:

	Birth Mother	Birth Father
Age
Highest grade completed/degree
Occupation
Special Education
Repeated a grade
Learning Disability
Attention-Deficit/Hyperactivity Disorder
Speech/Language difficulty
Psychiatric history

	Nonbiological caregiver #1	Nonbiological caregiver #2
Age
Highest grade completed/degree
Occupation
Special Education
Repeated a grade
Learning Disability
Attention-Deficit/Hyperactivity Disorder
Speech/Language difficulty
Psychiatric history

Other Children (including step-siblings and half-siblings)

	Name	Age	M/F	Living at home?	School/behavioral/health problems?
Child #1
Child #2
Child #3
Child #4
Child #5

Please tell us about any medical, cognitive or psychiatric troubles within your extended family (including grandparents, aunts/uncles, cousins, etc.)

learning problemsemotional/psychiatric problemsneurological problemsinterpersonal problems
Please explain
Please tell us about any religious or cultural considerations that you feel are important for us to know in working with you

OCCUPATIONAL HISTORY
Primary Patient's current occupation
How long has primary patient held this job?
How satisfied is the primary patient with his/her job?
Previous jobs
If retired, year of retirement
What is primary patients current job duties / requirements?
What is the primary patients job title or role?
Has the primary patient experiencing any troubles at work?

YesNo
If yes, please explain:
Has the primary patient been fired from any jobs?

YesNo
If yes, please explain:

MILITARY HISTORY
Has the primary patient served in the military?

YesNo
If yes, please clarify
Was the primary patient ever in combat?

YesNo
Was the primary patient ever injured?

YesNo
If yes, please clarify
Should be Empty:

	Not at all	Somewhat	A Lot
Fidgets
Difficulty remaining seated
Difficulty playing quietly
Often talks excessively
Runs about or climbs excessively
On the go or acts as if driven by a motor
Difficulty awaiting turn
Often blurts out answers to questions before completed
Often interrupts or intrudes on others
Often engages in physically dangerous activities
Difficulty following instructions
Difficulty sustaining attention
Shifts from one activity to another
Often does not listen
Often loses things
Easily distracted
Gives up easily
Inconsistent performance
Poor motivation
Disorganized
Doesn’t finish tasks
Low frustration tolerance
Poor handwriting
Mood swings
Often loses temper
Often argues with adults
Often actively defies or refuses adult requests or rules
Often deliberately does things that annoy other people
Often blames others for own mistakes
Is often touchy or easily annoyed by others
Is often angry or resentful
Is often spiteful or vindictive
Often swears or uses obscene language
Depressed or irritable mood most of day, nearly every day
Diminished pleasure in activities
Agitation or sluggishness
Feelings of worthlessness or excessive inappropriate guilt
Poor appetite or overeating
Trouble sleeping or sleeps too much
Low self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness
Repeated unusual movements
Odd postures
Excessive reaction to noise or fails to react to loud noises
Overreacts to touch
Compulsive rituals
Motor tics
Vocal tics
Can’t get to the point, loses train of thought
Bizarre ideas (e.g., odd fascinations, strange ideas, hallucinations)
Disoriented, confused, staring, or “Spacy”
Incoherent speech (mumbles, uses words only child understands)
Excessive mood swings
Explosive temper with minimal provocation
Excessive clinging, attachment, or dependence on adults
Unusual fears, repetitive worries
Panic attacks
Excessively monotonous or bland affect
Situationally inappropriate emotions
Little or no interest in peers or friends
Significant indiscreet remarks
Initiates or terminates interactions inappropriately
Abnormal social behavior
Excessive reaction to changes in routine

	Strongly agree	Somewhat agree	Neutral	Somewhat disagree	Strongly disagree
Quiet and content
Very easy to feed
Usually relaxed
Underactive
Cuddly, easy to hold
Easily calmed down
Cautious and careful
Coordinated
Enjoyed eye contact
Liked people

	Name	Age	Relationship to primary patient
Person #1
Person #2
Person #3
Person #4
Person #5
Person #6
Person #7
Person #8
Person #9
Person #10

Background History Form

PATIENT/PRIMARY CLIENT'S INFORMATION

INFORMATION REGARDING IMPORTANT PERSONS IN THE PRIMARY PATIENT'S LIFE

PLEASE LIST YOUR CONCERNS AND REASONS FOR SEEKING SERVICES

CURRENT STATUS OF PATIENT

EARLY HISTORY

EDUCATIONAL HISTORY

HEALTH INFORMATION AND HISTORY

FAMILY ARRANGEMENT

PARENTS HISTORY

OCCUPATIONAL HISTORY

MILITARY HISTORY

	Medication	Dosage	For what reason
1
2
3
4