Adult Assessment Form
Name
*
First Name
Last Name
Email
*
example@example.com
Your Date of Birth
*
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Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Handed
*
Left
Right
Mixed
Primary concerns
*
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Priority of issues for the client:
#1
#2
#3
#4
In the following sections, if symptoms are indicated, please include additional details in the "Additional Notes / information" field. If nothing applies, please write none.
I understand
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Sleep
Difficulty falling asleep
Restless sleep
Nightmares
Sleep walking or talking
Restless legs
Not rested after sleep
Sleep apnea / snoring
Narcolepsy
Other
Additional notes / information:
*
Type "none" or n/a if nothing applies
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Pain
Headaches
Stomach pain
Muscle tension pain
Arthritis (joint) pain
Chronic nerve pain
Chronic aching pain or stiffness
High pain tolerance
Low pain tolerance
Additional notes / information:
*
Type "none" or n/a if nothing applies
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Physical
Balance
Coordination
Spasticity / muscle tension
Tremor
Hyperactivity
Tics
Bruxism (teeth grinding)
Muscle Weakness
Additional notes / information:
*
Type "none" or n/a if nothing applies
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Physiology
Allergies
Asthma
Diabetes
Autoimmune
High blood pressure
Frequent illness
Nausea or vomiting
Dizziness / Fainting
Sugar craving and reaction
PMS/ menopausal symptoms
Thyroid / endocrine
Incontinence / enuresis
Chronic constipation / irritable bowel
Skin Problems
Additional notes / information:
*
Type "none" or n/a if nothing applies
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Emotions
Anxiety
Fear
Obsessive worries
Depression
Anger
Emotional reactivity
Phobias
Suicidal thoughts
Mood swings
Panic attacks
Lack of empathy
Additional notes / information:
*
Type "none" or n/a if nothing applies
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Behavior
Impulsive
Compulsive
Oppositional
Tantrums / rages
Aggressive
Thrill seeking
Self-injury
Addiction
Eating disorders
Additional notes / information:
*
Type "none" or n/a if nothing applies
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Attention
Focused attention
Organization and planning
Memory
Body awareness
Appetite awareness
Space and time awareness
Attention to detail
Distractibility
Impulsivity
Hyperactivity
Additional notes / information:
*
Type "none" or n/a if nothing applies
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Sensory / Cognitive
Vision
Hearing
Tinnitus
Verbal expression
Reading / writing
Math
Drawing
Sense of direction
Logic
Common Sense
Additional notes / information:
*
Type "none" or n/a if nothing applies
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Birth & early development
In utero or birth trauma
Prenatal stress or injury
Early developmental problems
Medical issues
Emotional development
Motor development
Language development
Early trauma or neglect
Adopted at age ____
Attachment problems
Additional notes / information:
*
Type "none" or n/a if nothing applies
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Brain injury or seizures
High fevers
Traumatic brain injury / Concussions
Stroke
Seizures
Other brain injury
Additional notes / information:
*
Type "none" or n/a if nothing applies
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Traumatic experience & stress
Physical trauma
Emotional trauma
Illness
Family stress
Death in family
School or Job stress
Other
Additional notes / information:
*
Type "none" or n/a if nothing applies
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Drug experience
Caffeine
Alcohol
Nicotine
Marijuana
Other
Additional notes / information (please specify how often any items checked off are used per week):
*
Type "none" or n/a if nothing applies
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Current medications (including supplements & vitamins):
Past medications (including supplements & vitamins):
Therapies
Psychotherapy
Physical therapy
Occupational therapy
Educational therapy
Medical treatments
Other
Additional notes / information:
*
Type "none" or n/a if nothing applies
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Family History: Symptoms
Rows
YES
NO
RELATIONSHIP TO CLIENT
Asthma
Autoimmune: Diabetes,
Rheumatoid Arthritis, Lupus, MS, etc
Thyroid
Migraine
Sleep problems
Depression
Manic- Depression
Anxiety
Phobias
Panic Attacks
Motor or Vocal tics
Seizures
Eating Disorders
Addictions
Obsessive Compulsive Symptoms
Speech Problems
Attention Problems
Hyperactivity
Learning Problems
Conduct Problems or Criminal Behavior
Autism spectrum
Schizophrenia
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