Adult Assessment Information Packet

List any other illness or accidents you have had below:

	Illness	Age	Treatment Given	Complication?
1.
2.
3.
4.
5.
6.

List any medications you are currently taking:

	Name	Dosage	Purpose	Prescribing Doctor	Length of Use
1.
2.
3.
4.
5.
6.

Have you had other special medical test (e.g., CT, MRI, EEG, etc.)?

YesNo

If yes, please describe date of test and results:

Do you have a history of any of the following?

	Yes	Age
Failure to thrive
Febrile seizures
Epilepsy
Staring spells
Lead poisoning/toxic ingestion
Meningitis/encephalitis
Asthma
Allergies
Diabetes
Loss of consciousness
Headaches
Abdominal pains/vomiting
Frequent ear infections
Ear tubes
Sleep difficulties
Eating difficulties/eating disorder
Ties/twitching
Impulsivity
Repetitive/stereotypic movements (eg, hand flapping)
Temper tantrums
Clumsiness
Head banging
Self-injurious behavior

Family Medical History

Has anyone in your family had any of the following?

	Yes	Who?
Neurological Disease
Seizures (Epilepsy)
Hearing problems
Visual problems
Psychiatric problems
Emotional problems
Alcoholism problems
Substance abuse problems
Slowness in talking
Slowness in walking
Hyperactivity
Learning problems
Similar problems to you

Does any disease run in the family?

YesNo

If yes, please describe:

Relationship Status:

Other

Spouse/Partner's name:

First NameLast Name

Age

Highest level of education:

Occupation:

Your parents are:

MarriedSeparatedDivorced

Other

Your mother/guardian's name:

First NameLast Name

Age

Occupation:

Highest level of education:

Your father/guardian's name:

First NameLast Name

Age

Occupation:

Highest level of education:

Mother/Guardian

Biological parentAdoptive parentStep-parent

Other

Father/Guardian

Biological parentAdoptive parentStep-parent

Other

If you are adopted, give legal date of adoption:

Adoption agency:

Location of birthplace:

People living in the same household as you:

	Name	Relationship	Age	Education (years)	Occupation
1.
2.
3.
4.
5.
6.
7.
8.

Siblings are:

	Name	Relationship	Age	Education (years)	Occupation
1.
2.
3.
4.
5.
6.
7.
8.

Have any of the following impacted you?

How often do you engage in social activities with family, friends or acquaintances?

Are you satisfied with your social support network?

YesSomewhatNo

Is there someone you can call when you are in distress?

YesNo

If yes, who

Do you have family and/or friends that support you?

YesSomewhatNo

How often do you exercise?

DailyWeeklyMonthlyRarely or Never

Are you currently seeing a counselor/therapist?

YesNo

Therapist's name:

Reason for treatment:

Duration of treatment:

Have you ever had thoughts/attempts to harm yourself?

YesNo

If yes, please describe:

Have you ever had thoughts/attempts to harm others?

YesNo

If yes, please describe:

Have you RECENTLY had thoughts to harm yourself and/or others?

YesNo

If yes, please describe:

Caffeine use:

Describe average amount/type of caffeine consumed:

Alcohol use:

Describe average amount/type of alcohol consumed:

Additional substance use:

Describe average amount/type of substance consumed:

Have the following applied to you?

Received treatment for issues related to alcohol and/or drug useAlcohol and/or drug use affected relationshipsFelt you should cut down on your drinkingOthers criticized your drinkingFelt bad/guilty about your drinkingHad a drink first thing in the morning to steady nerves or get rid of a hangover

Describe special areas of interest or hobbies or sports:

What would you identify as some of your personal strengths:

To which cultural or ethnic group, if any, do you belong

Do you experience any problems due to cultural or ethnic issues?

YesNo

If yes, please describe:

Adult Assessment Information Packet

II. Referral Information

III. Previous Evaluations

IV. Previous Services

IV. Pregnancy

IV. Developmental History

VII. Medical History

VIII. Behavior and Social History

IX. School/Occupational History

X. Additional Information

	Description	Date(s) Employed	Reason for leaving
1.
2.
3.
4.
5.
6.