How log have you had symptoms? *
On-going, off-and-on? *

Referred by:    *    

More than one? How many? *       
When/Age?    *    
Hospitalized/ER?    *    
Loss of Consciousness? For how long?    *    
Needed Rehabilitation?    *    

What diagnoses? *
How currently treated?    *    

When diagnosed?    *    
Special education?    *    
Repeat grade/Held back?    *    
What's your highest level of education?    *    

When diagnosed?    *    
Treatment history:    *    
Currently being treated?    *    
Evaluated in Childhood or Early Childhood:    *    
Neurological issues; migrates, medical:    *    

What diagnoses?    *    
When diagnosed?    *    
Ever need inpatient psychiatric hospitalization?    Yes     No *    
Currently treated with medications?     Yes     No *    
...... If Yes, By who?       For How Long?      
In counseling? With who?     *    

When?    *    
Did you hospitalized?    Yes     No *    Where you hospitalized?       

Ever been awake for a few days because you didn’t feel the need to sleep?   Yes     No *       
Had excess energy?    Yes     No *       
On the go with a race of thoughts?     Yes     No *    

What School? *
What are you going to school for (goal/major):    *    

Have you seen any other Doctors, Specialists, Counselors, Psychiatrists: *
Past or present diagnosis: *
Are you taking any medications?     *    
Past or present learning disabilities:    *    
Are your Physicals with a Primary Care Physician current?     *    
Have you had any recent blood work:    *    
Does blood work show any issues? Such as vitamin deficiency, thyroid functions:    *