Adult History Form

Preparing For Your Appointment During COVID-19 Emergency

Please allow 15-20 minutes to complete the form. Return it prior to your appointment. Bring your identification and wear a mask. We continue to screen for COVID symptoms and will take your tempurature at the reception area. We have your safety in mind and have made available masks, if you need one, and hand sanitizer .

Call 859-200-1990

Personal History

Today's date

Client's Name:

Date of Birth:

Age:

Person completing form and relationship to client:

Social Security Number:

Person driving to the office and type of vehicle:

Travel distace:

Social History

City and State of birth:

Who raised you?

How many brothers and sisters do you have?

What did your father do for a living while you were growing up?

What did your mother do for a living while you were growing up?

How old where you when they divorced?

If they did not get divorced, put N/A

Report if parent(s) died, which parent, when and how death happened:

Report abuse or violence growing up:

If none, put N/A

Report foster care or residential placement:

i.e. age, place, reason, length of stay

Number of times divorced:

Number of times widowed:

If other, please explain:

Report who else lives in the home with you:

If you are single, divorced, or widowed, are you dating now? If so, describe your relationship:

Number of children:

If child(ren) are under 18, and not living with you, describe current living arrangements:

Educational History

Name of last school attended:

Year graduated from high school:

If not, put N/A

If obtained GED, year obtained:

If not, put N/A

If you did receive special educational services, please report what grades and reason:

If you did go to an alternative school setting, what grade(s) and what reason:

If you did repeat a grade, which one(s) and what reason:

If you have taken any college or vocational classes, when, name of school, and study:

If you have a college or vocational certification or degree, report year, type of degree, in what decipline, and from college

i.e. 1994- associate degree in nursing from SCC

Employment History

Add new row

If you have been in the military, report branch, year enlisted/commissioned, rank at discharge, year discharged, type of discharge, MOS

i.e. USMC, March 1987-July 1991, Honorable, E-4/Cpl, 6541-Aviation Ordnance

Medical and Psychological History

Report hospitalizations for any medical or surgeries:

i.e. date, hospital name, and reason

Report hospitization for any mental health problems:

i.e. date, hospital name, and reason

Report any emergency room services in the past year:

i.e. hospital name, reason, and treatment provided

Report any history of loss of consciousness or head injury treatment:

i.e. date, hospital, treatment, length of stay

Current therapies being provided:

Occupational Therapy

Physicial Therapy

Speech Therapy

Counseling/Psychotherapy

Other Therapy

Primary Care Doctor:

Psychiatrist:

Counselor:

Current Medications:

Add new row

Legal History

Has your driver's license ever been suspended or revoked? If yes, when and what was the reason:

Add new row

Has anyone gotten a restaining order or emergency protective order against you? If yes, who and when?

Activities of Daily Living

Report the activities you do on a typcial day:

Time you go to bed:

Time you get up for the day:

How many hours do you spend each week doing chores?

What other activities take up your time?

If you did not check an item, describe the reason:

Report what you do for fun/hobby:

Your information will be encrypted.

Adult History Form

Preparing For Your Appointment During COVID-19 Emergency

Personal History

Social History

Educational History

Employment History

Medical and Psychological History

Current Medications:

Legal History

Activities of Daily Living

Preparing For Your Appointment During COVID-19 Emergency

Annette Freel

Licensed Psychological Practitioner, Kentucky Psychological Services