Adult History Form


    Email Address:

    Last Name:

    First Name:

    Marital Status:

    Address:

    City:

    State:

    Zip Code:

    Home Phone:

    Cell Phone:

    Email:

    Employer:

    Phone #:

    Spouse

    Name of Spouse:

    Home Phone:

    Cell Phone:

    Email:

    Spouse’s Employer:

    Employer’s #:

    Family Physician:

    Phone #:

    Insurance Name:

    Phone #:

    Name as it appears on card:

    Who referred you to Dr. Donna Estrecher?:

    Reason For Referral?:

    Please give a brief description of the problems you have for which you feel need help:

    Employment

    Please describe the nature of your current employment or studies, including any work related problems:

    What past jobs have you had? Indicate any problems you may have had with them:

    Family

    Please give the ages and relationship of persons in your immediate family, including parents, siblings, children and spouse. Beside each name, list any problems you were aware of such as psychiatric, behavior, alcohol, drugs, etc.

    Name:

    Relationship:

    Problems:

    Past School History:

    Please give a brief summary of what your academic and social experience in school was like. Try to recall both early grades and the later years of high school and or college. How did you get along with the teacher? Other students? Friends? What were your:

    Family Relationships:

    Briefly describe what your household was like when you were growing up. Describe what your current family relationships are like, both with your original family and your current family.:

    Medical History

    Describe any serious illnesses, accidents, diseases or medical conditions of which you are aware:

    Medications:

    List any medications you are taking with the dosages. List all psychiatric or neurological medications taken in the past.

    Name of Medication:

    Why taken:

    When taken:

    Dosage:

    Do you smoke?:

    If yes, how much? (Packs per day):

    Do you think you have had a drinking problem in the past?:

    On average, how often do you drink alcohol?:

    If you drink alcohol, how much do you consume at one time?:

    Have you had a drug problem in the past?:

    If yes, Describe:

    Do you currently use drugs?:

    If yes, what drug and how often do you use?:

    Have you ever been hospitalized for drug abuse treatment?:

    If yes, for what type of drug use?:

    When?:

    Name of facility:

    Duration of Treatment:

    Please note any further facts about yourself that you think might be helpful in understanding your current problems:

    Mental Health History

    Have you or anyone in your immediate family ever been in therapy before?:

    If yes, what for?:

    Duration of Therapy:

    Name of Therapist:

    Have you or anyone in your immediate family ever been hospitalized?:

    If yes, please explain:

    Name of facility:

    What for:

    Duration of Hospitalization:

    What is the MAIN problem for you at this time?:

    What have you tried to solve this problem?:

    Are you currently receiving any treatment for this problem?:

    Choose any family or life stresses that might have brought on or added to your problems:
    Financial PressureLegal ProblemsMove(s)Job ChangeDivorceSeparationDeath(s)IllnessBirth of ChildMental Illness Medical ProblemsTraumatic ExperiencesConflicts in Marriage/RelationshipOthers

    Please Check any of the Following that are Problems for you:
    Feelings of sadness, depressionFeeling very nervousDifficulty with sleepBeing very irritable, edgyNo energyDifficulty concentrating or memoryThinking about suicideThinking about hurting someoneAnnoying habits or behaviorsConcern about weightDifficulty with friendsDifficulty with spouse or partnerDifficulty with brother or sisterDifficulty with coworkers or bossDifficulty handling angerPanicDifficulty with eating, appetiteCrying too easilyUnable to enjoy anythingThinking about deathHearing voicesFeeling confusedFeeling out of controlConcern about appearanceDifficulty with parentsDiscouraged about the futureUnhappy with job or schoolOthers

    Comments:

    [recaptcha]