Adult History Form - Insurance Purposes

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859-200-1990

Personal History

Today's date

Patient's Name:

Date of Birth:

Age:

Person completing form and relationship to client:

Social Security Number:

Sex:

Male Female

Ethnicity:

Asian

African American

Caucasian

Hispanic

Other

Number of Children?

Who referred you to KY Psychological Services? (Agency, professional's name, and telephone #):

May I contact the agnecy/person to thank them for referring you?

Yes No

What is the main reason(s) you are seeking help?

When did these problems first start?

What are your hopes in completing a psychological evaluation?

PHYSICAL AND MENTAL HEALTH INFORMATION

Do you have any of these medical problems?

Fever

Yes No

Shortness of breath

Yes No

Do you have any other medical problems?

Who is your primary care doctor?

Do you see any specialist doctors?

Did you ever have a concussion or head injury?

Yes No

If yes, please describe:

Were you ever diagnosed with a psychological disorder?

Yes No

If yes, please describe:

Have you ever been in counseling before?

Yes No

If yes, when did you have counseling and for how long?

Who did you see for counseling?

Did it help you? How?

Have you ever seen a psychiatrist?

Yes No

If yes, for what?

Please list your CURRENT prescription medications with dosage (psychiatric and general health):

Add new row

YOUR CURRENT SYMPTOMS OR PROBLEMS

How much is EACH of the following areas currently a problem for you?

Have you ever had personality testing, IQ testing, or neuropsychological testing?

Yes No

If yes, please describe:

Have you had any losses or traumas in your life?

Yes No

If yes, please describe:

Have you ever been in a psychiatric hospital?

Yes No

If yes, please describe:

Have any of your family members been diagnosed or treated for a psychiatric problem?

Anxiety

Yes No