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Luzio & Associates Behavioral Services, Inc.
PATIENT INFORMATION - ADULT
OTHER HISTORY
SCHOOL
Client Name:
Do you attend school now?
NO
YES
Where?
How many hours/week?
Highest grade you have completed?
What school?
Did you have problems in school?
NO
YES
Describe:
Were you ever in special education classes?
NO
YES
What type and how long?
Overall, how would you describe your school experience?
GOOD
FAIR
POOR
Comments:
WORK
Do you work?
NO
YES
Where?
How many hours per week?
Job title / type of work
How long at this job?
How many jobs have you had in the past 5 years?
Have you had problems at work?
NO
YES
Describe:
Are you satisfied with your current work?
SATISFIED
UNSATISFIED
UNSURE
Comments about work history:
MILITARY
Are you a veteran of military services?
NO
YES
When / Where?
Highest Rank?
Ever reduced in rank?
NO
YES
How would you describe your military experience?
good
fair
poor
Describe:
Type of discharge:
LEGAL
Are you currently facing legal charges?
NO
YES
Charges:
Are you currently on probation, parole, or work release?
NO
YES
Probation/parole officer name:
List arrests:
Have you had any past legal charges?
NO
YES
Describe:
TRAUMATIC EXPERIENCES
Have you ever experienced or been a witness to a traumatic experience? (i.e., serious accident, disaster, crime, death of close relative, etc.)
NO
YES
Describe
Have you ever been physically assaulted?
NO
YES
Describe:
Have you ever been raped or sexually assaulted?
NO
YES
Describe:
MEDICAL INFORMATION
Do you have any medical problems?
NO
YES
Describe:
Is a doctor treating you?
YES
NO
Who is your doctor?
Doctor's Address
When did you last see a doctor?
When was your last physical exam?
What medications are you currently taking? (List both prescriptions and over-the-counter medicines)
I am not taking any medicine.
On an average day, how many caffeinated drinks (i.e. coffee, tea, sodas, etc.) do you consume each day?
Are you involved in any behaviors which would put you at high risk for contracting a communicable disease?
YES
NO
If yes, please select all that apply:
Use of drugs by injection
Unprotected sex with more than one partner
Other
Have you tested positive for communicable diseases?
YES
NO
Hepatitis
TB
HIV / AIDS
Other
If you need clarification of any of the questions on this form, please as your therapist.
What are your goals for therapy/treatment?
OTHER INFORMATION
What other information about your current problems should we know?
Send
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