06-08 Adult Personal History (Adult Admit Packet)

Adult Personal History

(18 and older)
Patient Name*

First NameLast Name
Email*
example@example.com
Date of Birth

MonthDayYear
Date
Person completing form for client:

First NameLast Name
Please take your time and complete entire form. The information will help your healthcare provider understand you better. Use the back of the last sheet of this form if necessary.
Reason for seeking help?
CHECK any of the following that apply to you now or within the past month (feel free to explain):

DepressionCrying spellsHopelessnessRelationship breakupLonelinessEmptinessLoss of appetiteSleep disturbanceNightmaresThoughts of harming selfThoughts of harming othersSuicide attempts/injuriesHearing voicesSeeing things others don’tUnusual thoughtsObstructive sleep apnea (OSA)Increased alcohol useIncreased drug usageBlackouts/memory lossWithdrawal symptomsFinancial worriesNervous/AnxiousPanic attacksCan’t concentrateConfusionMood swingsRacing thoughtsFear of dyingJob stressDecreased activityNot seeing friendsFeel controlledFeel talked aboutGuilt/shameSexual problemsSchool problems
Loss of control in

alcohol/drug useovereating/bingeing - purgingyelling/breakinghitting peopleendangering selfendangering others - spendinggambling
Ethnicity (check which one applies):

Hispanic or LatinHawaiian or LatinNot Hispanic or Latin
Race (check which one applies):

AsianNative HawaiianOther Pacific IslandBlack or African AmericanWhiteHispanicOther Pacific Islander
Physical Health:

Check each item that applied to you in the past or now:
1. Allergies2. Asthma3. Ulcers4. Cancer5. Stomach problems6. Pancreatitis7. Chronic pain8. Heart disease9. Bacterial endocarditis10. Seizures11. High Blood Pressure12. Low Blood Pressure13. Diabetes14. Hypoglycemia (Low blood sugar)15. Thyroid Problems16. Liver Disease17. Vision problems18. Hearing problems19. Speech problems20. Dental problems21. Weight loss22. Weight gain23. Severe headaches/migraines24. Frequent neck/shoulder pain25. Head injuries26. Physical Abuse27. Sexual abuse28. Premenstrual syndrome29. Sexually transmitted diseases30. Positive HIV31. AIDS32. Tuberculosis33. Hepatitis34. Major surgeries35. Chronic fatigue syndrome36. Impotence37. Prolapsed mitral valve38. Circulation problems39. High Cholesterol40. Irritable bowel41. Broken bones42. Accidents
Please list any surgeries you have had:
Allergies (list all):
Tobacco Use

YesNo
How much
Caffeine Use

YesNo
How much
Advance Directive

YesNo
Flu Shot

YesNo
Approximate DateLocation Administered
Pneumococcal vaccine

YesNo
Approximate DateLocation Administered

List of Medications:

	Medication	Dosage	Directions	Reason for taking
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Should be Empty: