06-08 Adult Personal History (Adult Admit Packet)

Adult Personal History

(18 and older)
Patient Name *

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

Month Day Year
Date
Person completing form for client:

First Name Last 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):

Depression Crying spells Hopelessness Relationship breakup Loneliness Emptiness Loss of appetite Sleep disturbance Nightmares Thoughts of harming self Thoughts of harming others Suicide attempts/injuries Hearing voices Seeing things others don’t Unusual thoughts Obstructive sleep apnea (OSA) Increased alcohol use Increased drug usage Blackouts/memory loss Withdrawal symptoms Financial worries Nervous/Anxious Panic attacks Can’t concentrate Confusion Mood swings Racing thoughts Fear of dying Job stress Decreased activity Not seeing friends Feel controlled Feel talked about Guilt/shame Sexual problems School problems
Loss of control in

alcohol/drug use overeating/bingeing - purging yelling/breaking hitting people endangering self endangering others - spending gambling
Ethnicity (check which one applies):

Hispanic or Latin Hawaiian or Latin Not Hispanic or Latin
Race (check which one applies):

Asian Native Hawaiian Other Pacific Island Black or African American White Hispanic Other Pacific Islander
Physical Health:

Check each item that applied to you in the past or now:
1. Allergies 2. Asthma 3. Ulcers 4. Cancer 5. Stomach problems 6. Pancreatitis 7. Chronic pain 8. Heart disease 9. Bacterial endocarditis 10. Seizures 11. High Blood Pressure 12. Low Blood Pressure 13. Diabetes 14. Hypoglycemia (Low blood sugar) 15. Thyroid Problems 16. Liver Disease 17. Vision problems 18. Hearing problems 19. Speech problems 20. Dental problems 21. Weight loss 22. Weight gain 23. Severe headaches/migraines 24. Frequent neck/shoulder pain 25. Head injuries 26. Physical Abuse 27. Sexual abuse 28. Premenstrual syndrome 29. Sexually transmitted diseases 30. Positive HIV 31. AIDS 32. Tuberculosis 33. Hepatitis 34. Major surgeries 35. Chronic fatigue syndrome 36. Impotence 37. Prolapsed mitral valve 38. Circulation problems 39. High Cholesterol 40. Irritable bowel 41. Broken bones 42. Accidents
Please list any surgeries you have had:
Allergies (list all):
Tobacco Use

Yes No
How much
Caffeine Use

Yes No
How much
Advance Directive

Yes No
Flu Shot

Yes No
Approximate Date Location Administered
Pneumococcal vaccine

Yes No
Approximate Date Location Administered

List of Medications:

Medication

Dosage

Directions

Reason for taking

Should be Empty: