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					                                                       Gonino Wellness Center

                                                        Adult Personal History
  Personal History                                                                                               Together ... we can make a difference!

Informant:                                                    If not patient:                                     Relationship:
Birthplace:                             FAMILY    OF   ORIGIN: intact / Remarriage(s) # of Marriages              M   :        # of Marriages     F   :
# of Full Siblings:                     # of Half Siblings:                          Birthorder:                  Age:
MOTHER:                                                                              Occupation:
Age:                                                                                 Is there contact?:
History of ETOH/Drug Abuse:                                                          History of Mental Illness:


FATHER:                                                                              Occupation:
Age:                                                                                 Is there contact?:
History of ETOH/Drug Abuse:                                                          History of Mental Illness:


  Family Characteristics

       Lower Socioeconomic Class                          Alcoholic                            Abusive                    Other
       Middle Class                                       Chaotic                              Controlling
       Upper Class                                        Distant                              Open

Family Psychiatric History:
Family Strengths / Weaknesses:

  Cultural Assessment

  Marital / Family

       Single                                             Conflictual                          Heterosexual
       Married #                                          Stable                               Homosexual
       Divorced #                                         Distant                              Bisexual
       Significant Relationship

                 Male                  Male                     Male                      Male                  Male                     Male
               Female                Female                   Female                    Female                Female                   Female
               Age ___               Age ___                  Age ___                   Age ___               Age ___                  Age ___
          Biological / Step /   Biological / Step /      Biological / Step /       Biological / Step /   Biological / Step /      Biological / Step /
               Adopted               Adopted                  Adopted                   Adopted               Adopted                  Adopted


Elizabeth Davis, LPC-Intern                                      Adult Personal History Form                                                            Page   1
  Social Development

          Easily forms friendships                                     Attends social functions                         Needs ^ social interaction
          Maintains friendships                                        Avoids social functions
          Supportive friends
          No close friends

Strengths:                                                                                    Weaknesses:


  Educational History

          Elementary                   Middle School                    High School                Bachelor       Masters        Doctoral
          GED                          Some College

          Good Student                                          Learning Disabilities:                         Extracurricular Activities
          Avg Student
          Poor Student                                          Regular Classes                                Sports
          Special Education                                     Advanced Classes

School Behaviors (Childhood):
          Truancy                                               Argumentative                            Fighting with Peers
          Poor Effort                                           Disruptive                               Attentive
          Repeated Grades                                       Expulsions                               Suspensions
          Drugs / ETOH                                          Difficulty with Peers


  Employment History

Occupation:                                                                                                                    Homemaker
Employed: Y / N                    Current Employer:                                                                           Never employed

          Part-time                                             Good work hx                     On Sick leave
          Full-time                                             Poor work hx                     On Disability


  Military History

          No military hx                                      Spouse in military                           Raised in military family
          Army           Navy                              Air Force         Marines                    Other:

      Dates of Service:            /    /             to    /    /
          Honorable     Dishonorable                                    Medical              Service Related Disability                AWOL
          Txt at VA Hospital

Comments:         (list combat dates if applicable)

Elizabeth Davis, LPC-Intern                                               Adult Personal History Form                                          Page   2

How important to you are spiritual matters?        Not  Little   Moderate     Much
Are you affiliated with a spiritual or religious group?   No    Yes (describe)
Were you raised within a spiritual or religious group?     No    Yes (describe)
Would you like your spiritual/religious beliefs incorporated into the counseling?  No                      Yes (describe)


Current Status
Are you involved in any active cases (traffic, civil, criminal)?  No    Yes
If Yes, please describe and indicate the court and hearing/trial dates and charges

Are you presently on probation or parole?          No        Yes
If yes, please describe

Past History
Traffic Violations            No    Yes                    DWI, DUI, etc.                No    Yes
Criminal involvement          No    Yes                    Civil involvement             No    Yes

If you responded Yes to any of the above, please fill in the following information.
 Charges                                  Date               Where       (City, State)           Results


Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor
activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, traveling, etc.)

Activity                                                   How often now?                       How often in the past?

  Medical/Physical Health
Check all that apply:
  AIDS                             Constipation                         Hepatitis                       Sore throat
  Alcoholism                       Chicken Pox                          High blood pressure             Scarlet Fever
  Abdominal pain                   Dental problems                      Kidney problems                 Sinusitis
  Abortion (#___)                  Diabetes                             Measles                         Small Pox
  Allergies                        Diarrhea                             Monomucleosis                   Stroke
  Anemia                           Dizziness                            Mumps                           Sexual problems
  Appendicitis                     Drug abuse                           Menstral Pain                   Tonsillitis
  Arthritis                        Epilepsy                             Miscarriages                    Tuberculosis
  Asthma                           Ear infections                       Neurological disorders          Toothache
  Bronchitis                       Eating problems                      Nausea                          Thyroid problems
  Bed wetting                      Fainting                             Nose bleeds                     Vision problems
  Cancer                           Fatigue                              Pneumonia                       Vomiting
  Chest pain                       Frequent urination                   Rheumatic Fever                 Whooping cough
  Chronic pain                     Headaches (___migraines)             Sexually Transmitted Diseases   Other (describe)
  Colds/Coughs                     Hearing problems                     Sleeping Disorders

Elizabeth Davis, LPC-Intern                        Adult Personal History Form                                             Page   3
  Medical/Physical Health continued

List any current health concerns
List any recent health or physical changes

Meal                   How often          Typical foods eaten                Typical amount eaten         Comments
                       (times per week)

  Breakfast            ____ / week                                              __No __Low __Med __High

  Lunch                 ____ / week                                             __No __Low __Med __High

  Dinner                ____ / week                                             __No __Low __Med __High

  Snacks                ____ / week                                             __No __Low __Med __High

Current Prescribed Medications                  Dose     Dates               Purpose                      Side Effects

Current Over-the-Counter Meds,                  Dose     Dates               Purpose                      Side Effects
Vitamins or Herbs

Are you allergic to any medications or drugs? ___No                     ___Yes (describe) ___________________________

                               Date             Reason                                     Results
 Last physical exam

 Last doctor’s visit

 Last dental exam

 Most recent surgery

 Other surgery

 Upcoming surgery

Family History of Medical Problems

Elizabeth Davis, LPC-Intern                              Adult Personal History Form                                     Page   4
  Medical/Physical Health continued
Please check if there have been any recent changes in the following:
___Sleep patterns            ___Eating patterns         ___Behavior                           ___Energy level
___Physical activity level   ___General disposition     ___Weight                             ___Nervousness/tension

Describe changes in areas in which you check above:

  Chemical Use History

                                                                                                          Used in last   Used in last
                                                                      Frequency    Age of       Age of     48 hours       30 days
                              Method of use and amount
                                                                        of use    first use    last use   Yes    No      Yes     No
  Over the counter
  Other drugs

Substance of Preference:
1.___________________________________                                3.___________________________________
2.___________________________________                                4.___________________________________

Describe when and where you typically use substances

Describe any changes in your use patterns

Describe how your use has affected your family or friends (include their perceptions of your use)

Reason(s) for use:
      ___Addicted              ___Build confidence                   ___Escape             ___Self-medication
      ___Socializatioln        ___Taste                              ___Other (specify) __________________

How do you believe your substance use affects your life?

Who or what has helped you in stopping or limiting your use?

Does (Has) someone in your family      (past/present)   have (had) a problem with drugs or alcohol?
___No ___Yes (describe)

Have you had withdrawal symptoms when trying to stop using drugs or alcohol? ___No ___Yes (describe)

Have you had adverse reactions or overdose to drugs or alcohol? ___No ___Yes (describe)

Elizabeth Davis, LPC-Intern                      Adult Personal History Form                                                   Page     5
  Chemical Use History               continued

Does your body temperature change when you drink? ___No ___Yes (describe)

Have drugs or alcohol created aproblem for your job? ___No ___Yes (describe)

  Counseling / Prior Treatment History

Your past and present history:

                                     No   Yes   When                           Where              Your reaction to overall experience
 Counseling / Psychiatric

 Suicidal thoughts/attempts

 Drug / Alcohol treatment


 Involvement with self-help groups
 (e.g. AA, Al-Anon, NA,
 Overeaters Anonymous)

Have family or significant others had counseling or treatment? ___No ___Yes (describe)

Please check behaviors and sumptoms that occur to you more often than you would like them to take place:
  Aggression                         Dizziness                              Irritability                      Sleeping problems
  Alcohol dependence                 Drug dependence                        Judgment errors                   Speech problems
  Anger                              Eating disorder                        Memory impairment                 Suicidal thoughts
  Antisocial behavior                Elevated mood                          Mood shifts                       Thoughts disorganized
  Anxiety                            Fatigue                                Panic attacks                     Trembling
  Avoiding people                    Gambling                               Phobias / Fears                   Withdrawing
  Chest pain                         Hallucinations                         Recurring thoughts                Worrying
  Cyber addiction                    Heart palpitations                     Sexual addiction                  Other (describe)
  Depression                         High blood pressure                    Sexual difficulties
  Disoreintation                     Hopelessness                           Sick often
  Distractibility                    Impulsivity

Briefly discuss how the above symptoms impair your ability to function effectively.

Any additional information that would assist us in understanding your concerns or problems

What are your goals for therapy?

Do you feel suicidal at this time? ___ No ___Yes (explain)

Elizabeth Davis, LPC-Intern                            Adult Personal History Form                                               Page   6
                                            FOR STAFF USE ONLY

     Therapist’s Signature / Credentials                                                 Date

     Supervisor’s Signature / Credentials                                                Date

     Physician Exam:                                            Release of Information:
     ___Required ___Not Required                                ___On File ___ Signed & Dated

Elizabeth Davis, LPC-Intern                   Adult Personal History Form                       Page   7

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