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Luzio & Associates Behavioral Services, Inc.
PATIENT INFORMATION - ADULT
Client:
Age:
Gender:
Date:
Preferred Name:
CURRENT PROBLEMS
Check all of the following behaviors, which you have now or had within the past six months.
Depressed mood nearly every day
Low interest or no pleasure in things you used to enjoy
Greatly decreased or increased appetite
Not able to sleep or sleeping too much
Restlessness or feel like you're being slowed down
Feeling tired all the time, lack of energy
Feeling hopeless, helpless and worthless
Poor concentration
Thoughts about hurting yourself or others
Worrying a great deal over many different things nearly every day
Feeling restless or on edge most days
Feeling easily fatigued or tired
Having difficulty concentrating or your mind going blank
Maving muscle tension
Having problems falling asleep, staying asleep or having restless sleep
Being quick to anger or easily frustrated nearly every day
Low self esteem
Make careless mistakes
Difficulty sustaining attention
Do not seem to listen when spoken to directly
Fail to finish things
Difficulty organizing tasks/activities
Dislike tasks of sustained effort
Lost or forget things
Easily distracted
Fidgets
Restlessness
Talk excessively
Difficulty waiting
Interrupting others
See, hear or smell things that other people don't?
Yes
No
If so, please give details.
Have thoughts that you cannot get out of your mind that you think of over and over every day?
Yes
No
If so, explain.
Have some behaviors you do over and during your day that seem to take up an hour or more of your time every day?
Yes
No
If so, explain.
Keep yourself on a very limited diet? Take lots of diet pills or exercise a lot every day? Eat a lot of food then make yourself vomit?
Yes
No
If so, explain.
Have panic attacks?
Yes
No
If yes, explain.
Have you had any recent thoughts about
not wanting to live
hurting yourself
hurting someone else
none of these
Have you ever:
made a suicide attempt
injured yourself on purpose
overdosed, on purpose or by accident
none of these
Have you ever experienced or been a witness to a traumatic experience?
YES
NO
Have you ever been physically assaulted?
YES
NO
Have you ever been raped or sexually assaulted?
YES
NO
Have you ever had any serious accidents or illnesses in the past?
YES
NO
Describe:
Have you had any counseling/treatment for emotional or alcohol/drug problems either in a hospital or an outpatient?
YES
NO
Describe:
FAMILY INFORMATION
Relationship Status:
never married
married
separated
divorced
widowed
other
Do you have children?
Yes
No
If yes, how many?
What are their ages?
In your relationships, has there ever been:
verbal abuse
physical
sexual abuse
List everyone who lives in your home
Please list any of your relatives who may have had: depression panic attacks, phobias, schizophrenia, alcohol or drug problems, seizures, hyperactivity, mental retardation, or other mental or emotional problems.
WORK
Are you currently employed?
YES
NO
What is/was your most current job?
What types of other jobs have you help in the past:
Did you have problems at other jobs?
YES
NO
If so, describe.
MILITARY
Are you a veteran of military services?
YES
NO
What branch?
Highest Rank?
Ever reduced in rank?
YES
NO
MEDICAL INFORMATION
Who is your doctor?
Do you currently have any medical problems?
YES
NO
Describe:
Are you currently taking any medications? (List prescription and over-the-counter)
YES
NO
Have you ever overused prescribed medications?
YES
NO
Which medicines?
Do you have vision problems?
YES
NO
Describe:
Do you smoke cigarettes/cigars/pipe?
YES
NO
How much do you smoke per day?
Check any of the following that you have problems completing in your daily life:
Transportation (walking, riding bike, driving, using public transportation)
Completing personal hygiene activities
Preparing food (reading and following directions, cooking, etc.)
Washing dishes/cleaning kitchen/sweeping floors/dusting/taking out trash, etc.
Doing laundry
Grocery shopping
Reading (newspapers, books, magazines, mail, etc.)
Exercising
Caring for children
Making telephone calls/remembering phone numbers
Outdoor work/lawn or garden work
Visiting with neighbors/friends/family/family members
Attending church or social gatherings
Doing hobbies
Remembering things in daily routine or life
Paying bills/handling money
Attending therapy
Taking medications on own as prescribed
Making and keeping appointments
Send
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