Adult - Personal Information Form

Behavioral Neuropsychology & BDTX
Adult - Personal Information Form
Name *

First Name Last Name
Initials *
DOB *
Today's Date

Month Day Year
Date
Who is your provider? *
Your Home Address

Mailing Address

Street Address Line 2

City State

Zip
Your Preferred Phone # *
Your Preferred email address
example@example.com
If in school/college, tell us which one
Grade or level
Relationship Status
If involved in a religion, which?
Who referred you to us at BDTX?
Phone # of person who referred you
What problems might you want to address or change?
Have you ever had a psychological assessment? What was unhelpful and helpful about it?
List of psychiatrists, psychologists, counselors, social workers, or mental healthcare providers you see now, or have seen in the past
Elementary School Education
What problems, if any, did you have in Elementary School? [All that apply]

No Problems Reading Learning to Read Mathematics Spelling Writing Memory Coordination Handwriting Foreign Language Executive Skills Organizational Skills Paying Attention in Class Paying Attention Home Long-Term Projects Completing Homework Procrastination Test Anxiety Behavior Problems Other
Please explain further how you struggled in Elementary School
Did you have a 504 plan or an IEP in Elementary School?
What accommodations did you get in Elementary School?
Middle School Education
What problems, if any, did you have in Middle School? [All that apply]

No Problems Reading Learning to Read Mathematics Spelling Writing Memory Coordination Handwriting Foreign Language Executive Skills Organizational Skills Paying Attention in Class Paying Attention Home Long-Term Projects Completing Homework Procrastination Test Anxiety Behavior Problems Other
Please explain further how you struggled in Middle School?
Did you have a 504 plan or IEP in Middle School?
What accommodations did you get in Middle School?
High School Education
What problems, if any, do you recall having in High School? [All that apply]

No Problems Reading Learning to Read Mathematics Spelling Writing Memory Coordination Handwriting Foreign Language Executive Skills Organizational Skills Paying Attention in Class Paying Attention Home Long-Term Projects Completing Homework Procrastination Test Anxiety Behavior Problems Other
Please explain what you struggled with in High School?
Did you have a 504 or IEP in High School?
What accommodations did you get in High School?
High School Graduation Date:

Month Day Year
Date
High School GPA:
What Activities did you do in your school years [clubs, church, activities, sports, etc]
College and or Grad School Education
What problems, if any, do you recall having in College/Grad School? [All that apply]

No Problems Reading Learning to Read Mathematics Spelling Writing Memory Coordination Handwriting Foreign Language Organizational Skills Paying Attention in Class Paying Attention Home Long-Term Projects Completing Homework Procrastination Test Anxiety Behavior Problems Other
Please explain how you struggled in College or Grad School?
Did you get accommodations in college or grad school?
College Graduation Date

Month Day Year
Date
College Major/Overall GPA
Employment History
What is your current job?
What is stressful about your present job?
Current Employment: How satisfied are you with your present job?

1

2

3

4

5

1 is No Satisfaction , 5 is Highly Satisfied
List other jobs you've had
Your Health History
Date of last physical exam

Month Day Year
Date
Who is your primary care provider?
What are your current or longer term health concerns?
What medications do you take?
What supplements do you take?
Have you ever used tobacco? Smoked, Chewed? If you quit, when?
Have you ever used drugs? Please list
Your Family History

Please check whether any relatives have had any of these problems. If yes, please specify in the next text box.

	Mothers's Family	Father's Family
Mental Health Problems
Learning Issues
Alcohol or Drug Abuse/Dependence
Intellectual Disability
Legal Problems
Inattention Issues
Hyperactivity
Anxiety Problems
Obsessions and or Compulsions
Perfectionism
Tics or Involuntary Movements
Anger Problems
Psychiatric Hospitalizations
Language or Speech Problems
Depression
Bipolar Disorder
Mood Problems
Emotion Regulation

Please explain about anything you checked above
Check any issue or problems you are currently experiencing:

Alcohol Use/Abuse Behavior Regulation Drug Use/Abuse Excessive Video/Gaming Memory Issues Obsessions or Compulsions Tics Procrastination Anger Management Learning Issues Excessive Activity Legal Issues Mood Regulation Organizational Problems Psychiatric Problems Anxiety Problems Depression Inattention Work Related Problems Medical Regimen Adherence Perfectionism Sleep Financial Problems Other
Use this space to explain further anything you checked above [if desired]
Your Personal Strengths
Important values in your life
How do you usually cope with stress?
Driving
How many speeding tickets have you received since obtaining your license?
Number of moving violations or accidents you've had since obtaining your license?
Have you ever had your license restricted, revoked, or suspended?
Explain driving issues further
Your Future
What would you like to be different for you in 3-6 months?
What would you like to be different for you in 12-24 months?
What would you like to be different for you in 5 years?
Did we miss information you would like us to know about you?

Should be Empty:

Adult - Personal Information Form

Elementary School Education

Middle School Education

High School Education

College and or Grad School Education

Employment History

Your Health History

Your Family History

Driving

Your Future