Registration - History Form (22 and older)

Please fill out this form to the best of your knowledge. If some questions are not applicable to you, write N/A. If you need more space or wish to make additional comments, please write on the back or attach a separate sheet.
Form completed by:
Relationship if not client:
Date form completed:

Month Day Year
Date
General Information - Adult Form
Full Name
First Middle Last
Handedness:

Right Left
Date of Birth:

Month Day Year
Date
Age:
Ethnic/Cultural Background:
Primary language spoken in the home:
Other language spoken in the home:
Referral Information
Who referred you?
Reason for Referral:
Who is your primary care doctor?
Phone:
If you involved in litigation, who is your attorney?
**If you DO NOT want us to send a copy of our report to the referral source

please mark here
Current Concerns
What is the main reason for your visit today?
How long have had concerns?
What are you hoping to achieve at the completion of this evaluation?

Foster/Adoptive Information:
When were you first placed in foster care?
Why were your placed in foster care?
Were you adopted?

Yes No
If yes, specify country of origin if international
Age when your were first in home:
Date of legal adoption:

Month Day Year
Date
When did you know you were adopted?
How many different foster care / adoptive placements did you experience?
What type of placements did you experience (e.g., orphanage, foster home, group home, shelter care, kinship home, hospitalization, etc.)?
Do you have any contact with biological parents?

Yes No
If yes, with whom, how often, how did it feel?

LIST ALL PEOPLE WITH WHOM YOU CURRENTLY RESIDE:

	Name of Household Members	Age	Gender	Relationship to You	Highest Grade Completed
#1
#2
#3
#4
#5
#6
#7
#8

Are you separated or divorced:

Yes No
When did you separate/divorce?
Who has physical custody of any children?
How often does the other parent see these children?
Have there been any major changes within the family life or your living situation that have affected you (e.g., deaths, moves, divorces, loss of job, etc.)?

⁭ No ⁭ Yes (describe below)

List any major life events in chart below

	Event	Date	Your Age	Notes
#1
#2
#3
#4
#5

Please list the approximate age at which you accomplished the following developmental milestones. If you feel the milestone is not appropriate yet for the age of your child, please write N/A. If unsure, please write DK

	Age
Smile in response (social smile)
Sit independently
Crawl independently
Walk independently
Say “mama” or “dada” specifically
Toilet trained (urine)

	Age
Know primary colors
Say the letters of the alphabet
Print first and last name
Tie shoes
Snap, zip, button clothing
Toilet trained (bowel)

Have you ever lost skills that at one time he/she was able to perform?

Yes No
If yes, please explain

Have any maternal family members ever received extra help in school, early intervention, or special education services?

Yes No
If yes, specify who and the reason
Personal/Social Information
What are your main hobbies and interests?
What are you most proud of about yourself?
What gives you the most difficulty?
How many close friends does you have?
Have friends drifted away recently?
Does you have a best friend?

Yes No
How long have you been friends?
Years/months
How easily does you make friends?

Worse than average Average Better than average
If so, what have you tried to change this?

	If you are still in school please list your courses and ratings	Excellent	Above Average	Average	Somewhat of a problem	Problematic
Course 1
Course 2
Course 3
Course 4
Course 5
Course 6
Course 7
Course 8
Course 9

Was testing been completed by school?

Yes No
Date:

Month Day Year
Date
(Please attach a copy of the school evaluation if you have it)
Present class placement:

Regular class Bilingual/ESL Gifted & Talented

Type a question
Should be Empty:

	Yes	Specify
Trouble breathing
Cord around the neck (# of times ____)
Knot in cord
Seizures
Hemorrhage (bleeding) in head
Hydrocephalus (water on the brain)
Cyanosis (turned blue)
Need for ventilation
Jaundice
Poor feeding
Required a blood transfusion
Vomiting / reflux
Floppy muscle tone
Incubator care
Infection
Fever

	Yes	No
Did not enjoy cuddling
Difficult to comfort
Excessive irritability
Difficult feeding
Extremely passive
Temper tantrums
Convulsions
Colic
Destructive behavior
Breathing problems
Was not calmed by being held or stroked
Excessive restlessness
Frequent head banging
Sleeping difficulties
Early learning problems
Withdrawn behavior
Poor eye contact
Unable to separate from parent
Failure to thrive/poor weight gain

	Medication	Dosage	Frequency	Start date – End date	Reason for discontinuing
#1
#2
#3
#4

	Yes	?
Ears (specify)
Poor Hearing
Chronic earaches/ infections
Draining ears
Eyes (specify)
Poor vision
Crossed eyes
Wears glasses

	Yes	?
Appetite, digestion, stomach problems
Frequent stomach aches
Poor eating habits
Frequent vomiting
Soiling or daytime accidents
Constipation
Problems with weight

General Information - Adult Form

Referral Information

Current Concerns

Services/Interventions Sought Previously

Family Background

Foster/Adoptive Information:

Pre-Natal Period

Birth History (Please approximate if you are unsure)

Post-Delivery Period

Developmental History

Medical/Health History

Family Medical History

Personal/Social Information

Educational History

Behavior

	Yes	No	?
Endocrine/ Gland
Thyroid problems
Diabetes
Hypo/Hyperpituitarism
Growth problems
Other:

	Yes	No	?
Blood Disorder
Anemia
Excessive bleeding or bruising
Leukemia
Sickle cell disease
Other:

	Yes	No	?
Nervous system
Frequent and/ or severe headaches
Seizures or convulsions
Tremors or twitches
Paper and pencil coordination problems
Balance or coordination problems
Other:

	Yes	No
Ear Tubes
Encephalitis
Meningitis
Poisoning or drug intoxication
Coma
Staring spells
Immune system disorders
Other significant illness

	Yes	No	?
Urine or bladder problems
Bedwetting
Daytime wetting or accidents
Urine infections
Other:
Chest or Breathing
Wheezing/ asthma
Other:

	Yes	Date/Month	Where	Results
Neurologic Evaluation
CT scan of head
MRI scan of head
EEG
Audiology or hearing evaluation
Vision evaluation
Genetic Testing
Other laboratory tests

	Yes	Relation to Family Member
Birth defect
Genetic disorder
Cerebral palsy
Severe head injury
Migraine headaches
Multiple sclerosis
Physical handicap
Tuberous sclerosis
Huntington’s chorea
Muscular dystrophy
Sickle-cell anemia
Seizures or epilepsy
Cancer
Diabetes
Heart Disease
Alcohol/ Drug abuse
Physical/ sexual abuse

	Yes	Relation to Family Member
Reading problem
Other learning disability
Speech/ language delay
Did not graduate from high school
Mental retardation
Autism/ Asperger’s/ PDD
ADHD
Oppositional/ defiant behaviors
Antisocial behavior
Aggression
Tics/ Tourette’s Disorder
Nervousness/ anxiety
Obsessive-Compulsive Disorder
Depression
Bipolar/ manic-depressive disorder
Schizophrenia
Other: (Specify)

	Not at all	Just a little	Pretty much	Very much	N/A
Do not pay attention to detail or makes careless mistakes with, for example, homework or house ‘chores’
Have difficulty keeping attention to what needs to be done
Do not seem to listen when spoken to directly
Do not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
Have difficulty organizing tasks and activities
Avoid, dislike, or do not want to start tasks that require ongoing mental effort
Lose things necessary for tasks or activities (keys, documents or books)
Am easily distracted by noises or other stimuli
Am forgetful in daily activities
Feel restless
Say things I later regret.
Can’t make myself care about things I should care about.
Have less energy.

	Not at all	Just a little	Pretty much	Very much	N/A
Talk too much
Blurt out comments, interrupt, or am opinionated.
Seem to miss the point of jokes or follow other peoples’ stories.
Don’t read as much as I use to.
Ask for help when I can do something myself or try to do things myself when I’ve been told not to.
Argue more than I used to
Have trouble keeping track of my medications.
Have more fender benders or other people don’t seem as comfortable being in the car with me.
Blame others for his or her mistakes or misbehaviors
Am touchy or easily annoyed by others
Is angry and resentful
Drink more than I used to
Threaten or intimidate others.
Watch more TV than I used to.
Lie to get out of trouble or to avoid obligations
Overdraw my checking account or go over the limit on my credit cards
Avoid certain places or people
Have nightmares

	Not at all	Just a little	Pretty much	Very much	N/A
Have used a weapon that can cause physical harm (bat, knife, brick, gun)
Have wondered if it might be better if I were dead
Feel flat, empty or disconnected from others
Can’t tolerate noise or crowds the way I used to.
Find most things to be too much work to bother with
Worry about things more than I used to
Am in pain much of the time
Have decreased interest or pleasure in daily activities
Have significant weight loss or gain, poor appetite or over-eating without deciding to diet or trying to gain.
Have difficulty sleeping or is sleeping too much
Startle easily or jumpier than I used to be.
Seems excessively agitated___or slowed down___ (check if positive)
Feels lonely, unwanted, or unloved; complains that “no one loves him or her”
Have difficulty making decisions.
Have feelings of hopelessness
Have talked about or attempted suicide
Feel that worry is difficult to control
Am restless or feels keyed up or “on edge”
Have headaches or stomachaches.
Am irritable or grouchy
Has muscle tension
Have repetitive behaviors, such as hand-washing, lining things up, checking on things before leaving a room or leaving the house, or mental acts such as a need to keep counting things or repeating words over and over.
Have thoughts that persist and keep coming back, that cause worry or anxiety
Smell or see things that others do not.