Adult Case History
General Information
Case history completed by:
First Name
Last Name
Client Name
First Name
Last Name
Pronouns to be used on report for client:
She/Her
He/Him
They/Them
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email*
*
example@example.com
Age*
*
Birthdate
-
Month
-
Day
Year
Date
Mobile Phone
Please enter a valid phone number.
Evaluation requested by:
First Name
Last Name
Spouse
First Name
Last Name
Parent
First Name
Last Name
Do we have your permission to consult with a parent or spouse if we need an additional perspective for historical background information?*
*
Yes
No
What do you hope to obtain from this evaluation?*
*
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Academic History
Education
College/University Attended
Degree
Year Achieved
1
2
3
CHRONOLOGICAL HISTORY OF SCHOOL ATTENDANCE
School
Private or Public?
Age Range
Grades Attended
Special-Ed?
1
Private
Public
Yes
No
2
Private
Public
Yes
No
3
Private
Public
Yes
No
Handedness*
*
Right
Left
Please describe any past academic difficulties:*
*
At what age was the problem first noticed?*
*
By whom?*
*
As a child were you ever held back a grade in school?*
*
Yes
No
Skipped a grade in school?*
*
Yes
No
Please explain:
CHRONOLOGICAL HISTORY OF DIFFICULTIES (school history and evaluation)
Date
Grade
Evaluations & Diagnoses
Special-Ed Services
Miscellaneous (Medication, etc...)
1
2
3
Psychoeducational Assessment?*
*
Yes
No
Psychoeducational Intervention?*
*
Yes
No
Psychoeducational Treatment Details:*
*
Speech/Language Assessment?*
*
Yes
No
Speech/Language Treatment?*
*
Yes
No
Treatment Details:*
*
Occupational Therapy Assessment?*
*
Yes
No
Occupational Therapy Treatment?*
*
Yes
No
Treatment Details:*
*
Physical Therapy Assessment?*
*
Yes
No
Physical Therapy Treatment?*
*
Yes
No
Treatment Details:*
*
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Mental Health
Please describe any current or past mental health difficulties, if any.
For example depression, anxiety, etc.
Have you received psychotherapy or psychological evaluation?
If so, did you receive a diagnosis? What treatment did you receive, and for how long? What are the name(s) of the professionals you worked with?
Have you received prescriptions to address your mental health?*
*
Yes
No
Please list current and past medications:
Medication Name
Diagnosis
Time Period
1
2
3
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DEVELOPMENTAL FUNCTIONING
Have you suffered from any known hearing loss?*
*
Yes
No
Hearing aid?*
*
Yes
No
Please explain:*
*
When was your hearing last tested? (Approximate date is fine.)
-
Month
-
Day
Year
Date
By whom?*
*
Do you have any known visual problems?*
*
Yes
No
Glasses?*
*
Yes
No
Contacts?*
*
Yes
No
Sighted?
Near
Far
More detail on your visual problems (if you like)
When was your vision last tested?
-
Month
-
Day
Year
Date
By whom?*
*
AUDITORY BEHAVIOR / ORAL LANGUAGE
As a child did you:
enjoy listening to music?*
*
Yes
No
seem to understand other people?*
*
Yes
No
play any instruments?*
*
Yes
No
enjoy being read to?*
*
Yes
No
enjoy watching television?*
*
Yes
No
have trouble listening w/ distractions?*
*
Yes
No
Any difficulty pronouncing certain words (i.e., enemy, spaghetti, multiplication)?*
*
Yes
No
Did people ever comment that your speech was hard to understand?*
*
Yes
No
As a child did you have difficulty acquiring new vocabulary words?*
*
Yes
No
Do (or did) you often have difficulties thinking of the word you want to say?*
*
Yes
No
Please explain:*
*
Can you easily follow oral directions?*
*
Yes
No
Any problems in understanding language?*
*
Yes
No
READING
As a child did you have any problems in reading (home and / or school)?*
*
Yes
No
Please explain:*
*
Do you enjoy reading for pleasure now?*
*
Yes
No
Please explain:*
*
What type of books do you enjoy reading?
WRITING
As a child did you experience any problems in writing (home and / or school)?*
*
Yes
No
Please explain:*
*
Have you been concerned with your spelling?*
*
Yes
No
Please explain:*
*
Are you more comfortable writing by hand or typing?
MATH
Any problems in mathematics (home and/or school)?*
*
Yes
No
Please explain:*
*
How was your:
Addition?*
*
Subtraction?*
*
Multiplication?*
*
Division?*
*
Fractions?*
*
Algebra?*
*
Math reasoning (problem-solving, word problems)?*
*
Practical math skills (making change, measuring, altering recipes)?*
*
ORIENTATION SKILLS
As a child, how was your judgment regarding right and wrong?*
*
Did you or do you have trouble shifting from one thought or activity to another?
*
Yes
No
Please explain:*
*
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Family
First Parent's Name
First Name
Last Name
First Parent's Age*
*
First Parent's Occupation*
*
First Parent's Handedness*
*
Right
Left
First Parent's Education*
*
Did this parent experience any learning problems in school?*
*
Yes
No
Please explain:*
Does this parent have speech problems?*
*
Yes
No
Please explain:*
Does this parent have hearing problems?*
*
Yes
No
Please explain:*
Do you have information to enter for a second parent?*
*
Yes
No
Second Parent's Name
First Name
Last Name
Second Parent's Age*
Second Parent's Occupation*
Second Parent's Handedness*
Right
Left
Second Parent's Education*
Did this parent have any learning problems in school?*
Yes
No
Please explain:*
Does this parent have speech problems?*
Yes
No
Please explain:*
Does this parent have hearing problems?*
*
Yes
No
Please explain:*
*
Does either parent have any history of drug or alcohol abuse?*
*
Yes
No
Please explain:*
*
Does either parent have any history of neurologic conditions (i.e., seizures, stroke, aneurysms, AVM, dementia)?*
*
Yes
No
Please explain:*
*
Does either parent have any history of psychological difficulties, hospitalizations, psychotherapy, or treatment with psychotropic medications?*
*
Yes
No
Please explain:*
*
Siblings
Name
M/F
Age
Learning/Psychological difficulties?
1
2
3
4
Other medical conditions in family or extended family:*
*
Yes
No
Please explain:*
*
What language is spoken in the home?*
*
Do you live with anyone?
Name
Relationship
1
2
3
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MEDICAL HISTORY
Current Physician(s):
Physician Name
Phone Number
Address
1
2
3
Were you adopted?*
*
Yes
No
At what age?*
*
Length of pregnancy:*
*
Please describe if either of your biological parents had a history of neurological or psychological learning difficulties or problems with substance abuse:
Were there any problems during the delivery?*
*
Yes
No
Please explain:*
*
Medical Conditions
Please describe any significant childhood or adult-onset medical conditions (e.g., measles, mumps, chicken pox, allergies, meningitis, hypothyroid, diabetes, ear infections, ...):
Condition
Notes
Age
1
2
3
4
Anything else to share about your medical history?
For example, significant surgeries, head injuries, major hospitalizations, and the ages when those events occurred.
NEUROLOGICAL CONDITIONS
Have you ever had a neurological exam (MRI, CT scan, EEG...)?*
*
Yes
No
Please describe:*
*
What was the concern that led to the exam(s)? When did they take place? What conclusions were made?
Any history of a head injury, convulsions, or seizures (febrile or other)?*
*
Yes
No
Any history of toxic exposure or lead poisoning?*
*
Yes
No
Other neurological problems (e.g., inattentiveness, headaches, distractibility...)?
GROSS MOTOR SKILLS
Do you have a history of gross motor difficulties, or as a child did you feel especially uncoordinated?*
*
Yes
No
Please explain:*
*
How is your hand-eye coordination when playing sports or games?*
*
SPEECH AND LANGUAGE DEVELOPMENT
As a child did you experience any notable speech or language delays?*
*
Yes
No
Please explain:*
*
PSYCHOSOCIAL / EMOTIONAL DEVELOPMENT
How is your relationship with your parent(s)?*
*
How is your relationship with your sibling(s), if any?
How many close friends do you have?*
*
How often do you get together socially? Daily, weekly, monthly, or less?
Do you have any difficulties maintaining friendships?*
*
Yes
No
Please explain:*
*
Have you been involved in any lasting or committed relationships with a significant other (e.g., boyfriend, girlfriend, partner, spouse)? For what length of time? Please describe:*
*
Do you spend a lot of time by yourself?*
*
Yes
No
Doing what?*
*
Are you comfortable being with groups of friends, or do you prefer to be with one friend at a time?*
*
SOCIAL / EMOTIONAL ADJUSTMENT
How would you describe your self–concept (how you generally view yourself)?*
*
How would you describe your temperment, fears, and sense of humor when you were a child?
How do you typically express your feelings?*
*
BEHAVIOR MANAGEMENT
Do you have difficulty controlling your emotions or temper?*
*
Yes
No
Have your emotions or temper affected your work performance?*
*
Yes
No
How is your typical behavior/performance on the job?*
*
Have you experienced any disciplinary actions at work?*
*
Yes
No
Please explain:*
*
As a child or adolescent how was your behavior at school? Any disciplinary actions?*
*
Has your ability to control your emotions ever interfered with your relationships with friends or significant others?*
*
Yes
No
Please explain:*
*
Describe any hobbies or extracurricular activities in which you regularly participated in high school, college, as well as at the current time:*
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EMPLOYMENT HISTORY
Please describe or list your employment history, including the length of time spent at each job and indicate if it was part – time or full-time (or please include a copy of your most recent resume).
Job Title
Length of Employment
Part-Time or Full-Time
1
2
3
Have you ever been fired from a job?*
*
Yes
No
Please explain:*
*
Do you drive?*
*
Yes
No
Has your license ever been suspended or have you ever received a ticket for a DUI?*
*
Yes
No
Please explain:*
*
Have you ever been arrested?*
*
Yes
No
Please explain:*
*
Have you ever or are you currently involved in any ongoing litigation?*
*
Yes
No
If yes, please explain (e.g., specify divorce proceedings, workman’s compensation, malpractice, etc.)*
*
ALCOHOL AND DRUG USE
Your responses are confidential.
Do you drink alcohol?*
*
Yes
No
How would you describe your use of alcohol?
How often do you drink, and how much?
Has your use of alcohol changed over time?
E.g. was there ever a period of regular or heavier use?
Have you used marijuana?*
*
Yes
No
How would you describe your use of marijuana?
How often, and how much? On average how many times per day, week, month, or year do you use? Has your usage changed over time?
Have you used other recreational drugs (e.g., LSD, Methamphetamine, Cocaine, Heroin, Mushrooms, Inhalants, GHB, Ecstasy, Salvia, PCP)?*
*
Yes
No
How would you describe your use of recreational drugs?
How often, and how much? On average how many times per day, week, month, or year do you use? Has your usage changed over time?
Has your consumption of alcohol, marijuana, or other drugs negatively impacted your life?
If so, describe any impact on your job, your family, school, and health. Has drug use been responsible for any injuries or accidents?
Have you ever been treated for addiction?*
*
Yes
No
Please explain:*
*
MEDICATION HISTORY
Anti-anxiety medication?*
*
Yes
No
Antidepressant medication?*
*
Yes
No
Please specify:
Medication Name
Amount
Period of Time
Prescription
1
Yes
No
2
Yes
No
3
Yes
No
4
Yes
No
Stimulant medication?*
*
Yes
No
Please specify:
Medication Name
Amount
Period of Time
Prescription
1
Yes
No
2
Yes
No
3
Yes
No
4
Yes
No
Pain medication?*
*
Yes
No
Please specify:
Medication Name
Amount
Period of Time
Prescription
1
Yes
No
2
Yes
No
3
Yes
No
4
Yes
No
Neuroleptic medication or Mood Stabilizers?*
*
Yes
No
Please specify:
Medication Name
Amount
Period of Time
Prescription
1
Yes
No
2
Yes
No
3
Yes
No
4
Yes
No
Sleeping Pills?*
*
Yes
No
Please specify:
Medication Name
Amount
Period of Time
Prescription
1
Yes
No
2
Yes
No
3
Yes
No
4
Yes
No
Anti-seizure medications?*
*
Yes
No
Please specify:
Medication Name
Amount
Period of Time
Prescription
1
Yes
No
2
Yes
No
3
Yes
No
4
Yes
No
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ADDITIONAL CONCERNS
Do you have any other questions or information that might be helpful in our evaluation?
RATING SCALE
How was your behavior as a CHILD. Please be sure to answer each item.
Never or Rarely
Sometimes
Often
Very Often
Failed to give close attention to details or made careless mistakes in my work.
Fidgeted with my hands or feet or squirmed in my seat
Had difficulty sustaining my attention in tasks or fun activities
Left my seat in classrooms or in other situations in which sitting was expected
Didn't listen when spoken to directly
Was restless
Didn’t follow through on instructions and failed to finish work
Had difficulty engaging in leisure activities or doing fun things quietly
Had difficulty organizing tasks or activities
I felt “on the go” or “driven by a motor”
Avoided, disliked, or was reluctant to engage in work that required sustained mental effort
Talked excessively
Lost things necessary for tasks and activities
Blurted out answers before questions had been completed
Was easily distracted
Had difficulty awaiting my turn
Was forgetful in daily activities
Interrupted or intruded on others
How old were you when any of these problems were noticed?
To what extent have the problems you identified above interfered with with your ability to function in each of the following areas of life during the past 6 months?
Never or Rarely
Sometimes
Often
Very Often
In my home life with my immediate family
In my social interactions with other people
In my activities or dealings with the community
In school
In work
In sports, clubs, or other organizations
In taking care of myself
In leisure or recreational activities
In my handling of daily chores or other responsibilities
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