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Luzio & Associates Behavioral Services, Inc.
PATIENT INFORMATION - ADULT
Client:
Age:
Gender:
Date:
Preferred Name:
CURRENT PROBLEMS
Please describe the problems that you are having.
When did the current problems start?
Have you had problems like this before?
Yes
No
If so, when?
Who referred you?
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? Eats a lot of food then make yourself vomit?
Yes
No
If so, explain.
Have panic attacks?
Yes
No
If yes, explain.
List any other counseling/treatment you have had for emotional or alcohol/drug problems, either in a hospital or an outpatient:
What other problems are you having?
Family
Marital
Work
Legal
Money
School
Social
Other
Please describe:
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
Comments:
FAMILY INFORMATION
Relationship Status:
never married
married
separated
divorced
widowed
other
How many times have you been married?
How long have you currently been married?
Do you have children?
Yes
No
If yes, how many?
What are their ages?
If not married, are you in a relationship?
How long have you been in the relationship?
Are you satisfied with your current relationship (married or unmarried)?
Yes
No
In your relationships, has there ever been:
verbal abuse
physical
sexual abuse
Describe:
Where you live, do you:
own/rent
live in someone else's home
homeless
other
List everyone who lives in your home
FAMILY
Is your father living?
NO
YES
If yes, what is his age?
His employment?
Is your mother living?
NO
YES
If yes, what is her age?
Her employment?
Do you have sister/brothers?
NO
YES
If yes, how many sisters
If yes, how many brothers
Were you?
oldest child
youngest child
middle child
other
Relationship with your parents?
good
fair
poor
Comments:
Relationship with your siblings?
good
fair
poor
Comments:
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.
CHILDHOOD
How would you describe your childhood?
good
fair
poor
Comments:
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