Adult Personal History

First Name

Last Name

Date

Date of Birth

Age

Form completed by (if someone other than client)

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Home Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

If Other, specify

Family Information

Mother

Name

Age

Father

Name

Age

Spouse

Name

Age

Child

Add new row

Other

Add new row

Marital Status

Single

Length of Time

Legally Married

Length of Time

Widowed

Length of Time

Divorce in progress

Length of Time

Separated

Length of Time

Annulment

Length of Time

Unmarried, living together

Length of Time

Divorced

Length of Time

Parental Information

Parents legally married

Parent have been separated

Parents ever divorced

Mother remarried: Number of times

Father remarried: Number of times

Special circumstances (e.g. raised by person other than parents, information about spouse/children not living with you, etc.)

Development

Are there special, unusual, or traumatic circumstances that affected your development?

Yes No

If Yes, please describe

Has there been a history of child abuse?

Yes No

If yes, the abuse was as a

Victim Perpetrator

If yes, which type(s)?

Sexual

Physical

Verbal

Other childhood issues

Neglect

Inadequate nutrition

Other

If Other, specify

Comments regarding childhood development

Social Relationships

Specify Other

Sexual Orientation

Sexual dysfunctions?

Yes No

If Yes, Describe

Any current or past history of being a sexual perpetrator?

Yes No

If Yes, Describe

Cultural/ Ethnic

To which cultural or ethnic group, if any do you belong?

Are you experiencing any problems due to cultural or ethnic issues?

Yes No

If Yes, please describe

Other cultural/ethnic information

Spiritual/Religious

How important to you are spiritual matters?

Not Little Moderate Much

Are you affiliated with a spiritual or religious group?

Yes No

If Yes, please describe

Would you like your spiritual/religious beliefs incorporated into the counseling?

Yes No

If Yes, please describe

Legal

Current Status: Are you involved in any cases (traffic, civil, criminal)?

Yes No

If yes, please describe and indicate the court and hearing/trial dates and charges.

Are you currently on probation or parole?

Yes No

If yes, please describe

Past History

Please choose all that apply

Traffic violations

DWI,DUI, etc..

Criminal involvment

Civil involvement

If you responded yes to any of the above please fill out following information.

Charges, date, Where(City), Results

Education

Fill in all that apply

High School grad/GED

Number of Years

Major

Vocational

Number of Years

Major

College

Number of Years

Major

Graduate

Number of Years

Major

Other training

Special circumstances (e.g. learning disabilities, gifted)

Employment

Currently

Full Time

Part Time

Temp

Laid-Off

Disabled

Retired

Social Security

Student

Other

If Other, specify

Begin with most recent job, list job history

Add new row

Military

Military experience?

Yes No

Combat experience?

Yes No

Please expand

Add new row

Leisure/Recreational

Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness,sports, outdoor activities, church activities, walking, exercising,diet/health, hunting, fishing, bowling, traveling, etc.)

Medical/Physical Health

List any current health concerns

List any recent health or physical changes

Nutrition

Meals

Breakfast

Times per week eaten

Typical foods eaten

Lunch

Times per week eaten

Typical foods eaten

Dinner

Times per week eaten

Typical foods eaten

Snacks

Times per week eaten

Typical foods eaten

Comments

Current prescribed medication(s)

Current over the counter medication(s)

Name, Dose, Dates, Purpose, Side effects

Are you allergic to any medications or drugs?

Yes No

If Yes, describe

Medical

Last physical exam

Date

Reason

Results

Last doctors visit

Date

Reason

Results

Last dental exam

Date

Reason

Results

Most recent surgery

Date

Reason

Results

Other surgery

Date

Reason

Results

Upcoming surgery

Date

Reason

Results

Please list any family history of medical problems

Please check if there has been any recent changes in the following

Sleep Patterns

Physical activity level

Eating patterns

Behavior

Weight

General disposition

Energy level

Nevousness/tension

Describe changes in any areas in which you checked above

Chemical Use History

Alcohol

Method of use and amount

Frequency of use

Age of first use

Age of last use

Barbiturates

Method of use and amount

Frequency of use

Age of first use

Age of last use

Valium/Libium

Method of use and amount

Frequency of use

Age of first use

Age of last use

Cocaine / crack

Method of use and amount

Frequency of use

Age of first use

Age of last use

Heroin / Opiates

Method of use and amount

Frequency of use

Age of first use

Age of last use

Marijuana

Method of use and amount

Frequency of use

Age of first use

Age of last use

PCP / LSD / Mescaline

Method of use and amount

Frequency of use

Age of first use

Age of last use

Inhalants

Method of use and amount

Frequency of use

Age of first use

Age of last use

Caffeine

Method of use and amount

Frequency of use

Age of first use

Age of last use

Nicotine

Method of use and amount

Frequency of use

Age of first use

Age of last use

Over the counter

Method of use and amount

Frequency of use

Age of first use

Age of last use

Prescription drugs

Method of use and amount

Frequency of use

Age of first use

Age of last use

Other drugs

Method of use and amount

Frequency of use

Age of first use

Age of last use

Substance of preference

1. Substance Name

2. Substance Name

3. Substance Name

4. Substance Name

Substance Abuse Questions

Describe when and where you typically use substances

Describe and changes in your use patterns

Describe how your use has affected your family and friends (include their perceptions of your use)

Reason(s) for use

Addiction

Socialization

Build confidence

Taste

Escape

Self-medication

Other

If Other, please specify

How do you believe your substance use affects your life?

Who or what has helped you in stopping or limiting your use?

Does/Has someone in your family present/past have/had a problem with drugs or alcohol?

Yes No

If Yes, describe

Have you had withdrawal symptoms when trying to stop using drugs or alcohol?

Yes No

If Yes, describe

Have you had adverse reactions or overdose to drugs or alcohol?

Yes No

If Yes, describe

Does your body temperature change when you drink?

Yes No

If Yes, describe

Has drugs or alcohol created a problem for your job?

Yes No

If Yes, describe