Adult Clinical Intake Questionnaire

AUBREY K. EWING, PH.D. & ASSOCIATES, P.A.
1230 So. Federal Hwy, Boynton Beach, FL 33435

ADULT CLINICAL INTAKE QUESTIONNAIRE

The questions on the following pages ask you to provide information about why you are seeking counseling or other psychological services. They ask about your general emotional and physical health, pertinent history, how you are feeling now, and what concerns are most important to you. The questionnaire gives your doctor/therapist a head-start in understanding how to be of help to you.

This information will become part of your confidential record with this office and will not be released to anyone without your written permission. Your answers to these questions are considered protected health information (PHI) and are relayed to our office by a secure, HIPAA compliant process. We are committed to ensuring your privacy and protecting our confidential relationship.
Name
Email address to send confirmation of form receipt
example@example.com
Date of birth

MonthDayYear
Date
Age
Gender
Primary physician
Marital status
Name of spouse/partner
Your occupation
Employer/school
What is the primary reason for your visit at this time?
List the three behaviors or symptoms that concern you the most. Start with the most troubling first and work your way down.
When did you first notice having these behaviors or symptoms?
What are you most worried might happen if things continue as they are?
What are the most stressful things in your life that are affecting you right now?
Did you ever have similar behavioral or emotional problems that concerned you when you were younger?
If yes, please describe these problems, when they occurred, and what was done about them?
Have you ever seen anyone for help with behavioral or emotional problems?
If so, how old were you at the time?
Who did you see?
Did it help?
Have you ever taken medicines to help with behavioral or emotional problems?
If yes, how long ago?
Please list all the medications you have taken in the past (not your current meds):
List any medical problems for which you are currently being treated. Please indicate if a problem has been ongoing requiring regular or periodic care.
List any past hospitalizations you have had for medical, surgical, chemical dependency, or psychiatric reasons.
List any medications to which you are allergic or that you could not take due to intolerable side effects.
Please list all medications you are currently taking. Include birth control, vitamins, and over the counter drugs. Please include the name of the prescribing doctor.
FAMILY HISTORY

Has any relative on either parent's side of the family had any of the following?
Nervousness or panic

Mother' sideFather' side
Depression

Mother's sideFather's side
Obsessive-compulsive problems

Mother' sideFather' side
Bipolar disorder (manic depressive illness | cycling mood)

Mother' sideFather' side
Suicide

Mother' sideFather' side
Alcohol or drug problems

Mother' sideFather' side
Police record (arrests, jail)

Mother' sideFather' side
Schizophrenia

Mother' sideFather' side
Intellectual disability (formerly mental retardation)

Mother' sideFather' side
Developmental problems (autism spectrum disorder)

Mother' sideFather' side
Learning disoder (specific LD, dyslexia, other)

Mother' sideFather' side
Attention problems (ADD, ADHD)

Mother' sideFather' side
Tourette's or other tic problems

Mother' sideFather' side
Other conditions or more detail about answers above
HISTORY OF BEHAVIORAL OR EMOTIONAL EVENTS AND PROBLEMS
Please place a check in front of all that apply to you:

had to repeat a grade in schoolwas in at least one special education class or an SE curriculumwas told by teacher or other professional you have a learning disabilityhave been in accelerated classes for smart kids
I experience the following at home, work, or school:

often leave things unfinishedam easily distractedhave difficulty concentrating on reading or homeworkhave difficulty sitting stillfeel restless or fidgetyam impulsive--I sometimes act without thinkingoften misplace or lose thingsam easily forgetful and need frequent reminders
The following describe traits that I have or things that I've done:

am usually stubborn or self-willedhave trouble conforming to rules or regulationstend to argue with my boss/coworkerslose my temper easily, sometimes break/throw thingshave shoplifted or stolen somethinghave injured or killed a pet or small animal just for amusementhave broken or destroyed someone else's property (something of value or importance)have a reputation for starting fightshave pulled a knife or gun on someonehave set fires that were potentially dangeroushave tried to steal things by threatening someonehave tried to force another person to have sex
Check all of the following that apply to you:

I smoke cigarettes regularlyI drink beer, wine, or other alcoholic beveragesI have used alcoholic beverages to excessmissed school (or was asked to leave) because of drinkingmissed work (or was asked to leave) because of drinkinghave sniffed fumes (whippets, poppers, glue, gasoline, other inhalants) to get highhave smoked marijuana (pot, weed, grass)have used amphetamines (crystal meth, ice, speed, ADHD medication) to get highhave used cocaine (coke, crack, rocks)have used hallucinogens (LSD, PCP, peyote, mescaline)have used heroin, opiates (junk, smack, horse, H, fentanyl)have abused prescription medication (roxys, oxys, pain, sleep, etc.)have abused sedatives, tranquilizers (downers, bars, Xanax)am regularly using some of the above substances now?
Provide details about alcohol or other substance use/abuse (amount, frequency, etc.) that will clarify the extent of your use
I have had a period of two weeks or longer (now or in the past) when I:

didn’t feel much like eating or lost weightfelt like eating more than usual or gained extra weighthad trouble falling asleep or staying asleepslept more than usual or had trouble waking upwithdrew from family and friends, talking less than usuallost interest in things I usually like to dofelt tired all the time but wasn’t physically sickfrequently complained of aches headaches, stomachaches, etcfelt guilty over things I really wasn’t to blame forfelt worthless and thought I would be better off deadcouldn’t concentrate on work/school as welltalked about or tried to kill myselfthought a lot about death or dyingI am now feeling sad, blue, moody, or irritableI have experienced at least five of the items I have checked in this section continuously for the past two weeks or longer
I have had a period of at least one week or longer (now or in the past) when I:

was so overly happy or “high” that I got into troublebecame more overactive than usual to the extent that it made others concernedtalked faster or more constantly than usualhad thoughts were going very fast (racing) in my headthought I had special powers to do remarkable thingsslept a lot less than usual without appearing or feeling tiredwas unable to concentrate on things as usualdid extravagant things I later regretted (grand promises, travel, sex, spent money)
The following describe traits I have or things I have experienced:

I consider myself to be an anxious personI have had an anxiety attack without apparent reason.
If you answered "yes" to the question above, how often do you have panic or anxiety attacks?
During an anxiety attack, I have trouble catching my breathMy heart races too fastMy face becomes flushed or my hands begin to sweatI tend to worry a lotI sometimes think too much about health concerns or illness
Please check the following that are true about you:

I sometimes seem to have unusual and troublesome thoughts that I can’t put out of my mind (getting hurt, health, germs, bugs, etc)I have special habits or rituals that seem excessive or unnecessary(counting things, touching, hand washing, or similar)I check and recheck excessively on things already done, like turning off a light, or closing a doorI tend to get highly upset when things are not in their exact placeCertain numbers or sequences have special meaning to me
I think I am too fat?I have lost excessive weight intentionallyI exercise with the intent to lose weightI have lost more than ten pounds intentionallyI have gone on excessive eating bingesI have made myself vomit after binges or mealsI have tried diet pills or laxatives to lose weight
I have sudden, jerky movements, which are repetitive, like neck jerks, eye blinking, mouth twitches, shoulder shrugs, or ticsI have now or in the past had a habit of making repetitive sounds such as sniffs, grunts, throat clearing, barking or similarI have now or in the past had a habit of rocking my body or moving my fingers and hands in a repetitive way
Have you ever had thoughts or sensory experiences that confused you such as (check the boxes that apply):

thinking someone was out to get you?thinking that others could control your thoughts?hearing voices in your head that seemed real and were saying strange things?seeing things, having visions that others don’t see?
Have you ever had biofeedback or neurofeedback training/treatment?
If yes, please describe why you were referred for biofeedback, the type you received to the best of your knowledge, and if it was effective.
Please check this box to indicate that you have responded to all the items on this questionnaire that pertain to you.
Thank your for taking the time to answer these important questions. This information is helpful to the doctor/therapist in understanding your needs and how to best be of help to you.
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