GENERAL OVERVIEW OF HISTORY

I. INTRODUCTION - Get acquainted - put patient at ease "chit-chat"

II. IDENTIFICATION - Date, name, address, age, sex, marital state, occupation

III. REASON FOR REFERRAL

Referred by:
Reason for referral:
Patient's statement of the problem

Focus on symptoms, number, onset, duration, & course.
Prioritize symptoms.

VI. PAST HISTORY - Serious illness, operations, injuries.

VII. FAMILY HISTORY - State of health or cause of death of parents, brothers and sisters; history of diabetes, cancer, tuberculosis, heart disease, allergy.

VIII. SOCIAL HISTORY - Use of drugs, alcohol, tobacco - Happiness state, reactions to life situations of stress and conflict.

BEHAVIORAL OBSERVATIONS

I. Physical Description

a. Appearance consistent or inconsistent with stated age
b. Body build
c. Personal hygiene
d. Clothing
e. Noticeable physical defects (e.g., vision, hearing, gait, scars)
f. Other

II. General Behavior during Evaluation

A. Attitude toward evaluation
B. Speech

1. Speech difficulties
2. Flow
3. Content elaboration
4. Appropriateness
5. Manifest affect
C. Posture
D. Memory
E. Overt signs of agitation, tension, apprehension, or depression
F. Unusual behaviors

HISTORY: GENERAL

Identification:

Date:
Name:
SS#:
Address:
Age:

Reason for referral

Referred by:
Reason for referral:

Patient's statement of the problem

1. Current status
2. Previous episodes and hospitalizations
3. Relative severity and frequency
4. Precipitating stress

Symptoms:

List of symptoms
Severity of each
Change in each
Prioritize by magnitude

Medical History:

Were you a premature baby?
Did you have any birth defects or complications after delivery?
Childhood diseases or developmental problems
Previous major illnesses
Previous automobile accidents, head injuries, or loss of consciousness
Exposure to toxic substances
Electric shock
Any current health problems:

High blood pressure
Diabetes
Seizures
Dates and places of treatment (hospitals, rehab centers, neurologists, psychiatrists, physical therapists, etc.)

Family Background:

Are your parents still living?
(If not, what was their cause of death?)

Ages and occupations of parents
Are they still married?
If divorced, when?
Do your parents have any major health problems?
Were you physically or emotionally abused as a child?
Ages and occupations of brothers and sisters
When you were growing up, was your family actively involved in any religion?
Are you still actively involved?

Siblings:
How many, age, sex, occupation, marital status
Relationship with Significant others

Current Family Information:

Are you married?
If so, how long?
Is this your first marriage?
Do you currently live with your wife (husband)?
Spouse's name, age, and occupation
How would your describe your marriage?
Names and ages of children
If divorced, who has custody of the children?
Do you have visiting privileges?
If so, how often?
Are you responsible for administering discipline, or does your spouse handle that?
Does anyone else live in your home? (Name, age, and relationship)
Any special friends?
Do you get along with your friends as well as before?

Drug History

Current alcohol consumption (amount and frequency)
Current use of any non-prescriptioned drugs (type, frequency, & amount of use)
Any past history of alcohol or drug abuse?
If so, how much and for how long
Were you ever hospitalized for that condition?
Do you smoke? Is so, amount and number of years

Educational History:

Average grades in high school or college?
Highest academic achievement (grade level)
Academic performance (grades)
Attitude toward school authorities
Attitude toward education in general
Did you ever have any special tutoring or were you placed in any special classes?
Did you ever fail or have to repeat a grade?
Did you have any difficulties with any subjects?
If yes, which ones?
Subjects of special interest or strengths and weaknesses
Reason for discontinuing education
Were you ever told that you were hyperactive or had ADD/ADHD?

Legal History:

Have you ever been arrested?
What happened?
Type and length of sentence?
Is your case involved in litigation?
Name of attorney?

Present Living Situation:

With whom
Support System
Patient's Attitude

Employment History:

Occupational history
Nature of job
Duration held
Attitude towards
Reason for termination
Best job and why
Occupational aspirations

Psychological History:

Have you ever been a patient in a mental hospital?
If so, when, where, and for what reason?
Length of stay?
Type of treatment?
Medications?
Electric Shock?
Have you ever seen anyone for counseling or psychotherapy?
If so, when, where, and for what reason?

Recreation and interests:

How do you spend your free time?

General Information

Subject ID#
Date
Name
Age
Date of Birth
Is English your primary language?
Referred by:
Reason for Referral
Accident History:
When did injury/accident occur?
What happened?
What hospital were you taken to?
Were you admitted?
Length of stay?
Loss of consciousness?
How long?
PTA
RA

What were your injuries/symptoms at that time?

Dates and places of subsequent treatment (hospitals, rehab centers, neurologists, psychiatrists, physical therapists, etc.)
Current problems/symptoms (rank order)
Are you able to manage all your previous household chores?
How do you manage transportation?
Drive self?
Driven by family member or friend?
Public transportation
Any changes in taste or smell?
Changes in concentration? memory?
Changes in energy level?
Problems with depression or anxiety?
Problems with anger/impatience/impulse control?
Hallucinations (auditory or visual)?
Current medications

Post Injury Employment:

Have you returned to work (school) since injury?
If so, when?
How many hours do you work per week?
Place of employment (school)
Job description (academic load)

Is this the same job you had prior to your injury?
If yes, how long have you worked there?
If no, what type of work did you do previously & why are you not working there now?

Any problems since returning to work (school)
Do you get along with coworkers as well as before?
Has your amount of income changed since the injury/illness?_____
If so, how much?________________________________________________
Sources of income (circle all that apply):

Self Parents Sick leave
Spouse Extended family Retirement
Children Insurance Other

Do you currently receive any disability/compensation?
If so, type and amount per month
Previous job history (place, how long, and reason for leaving)

Current Family Information:

Are you married?
If so, how long?
Is this your first marriage?
Do you currently live with your wife (husband)?
Spouse's name, age, and occupation
How would your describe your marriage?
How has your injury affected that relationship?
Names and ages of children
If divorced, who has custody of the children?
Do you have visiting privileges?
If so, how often?
Has the injury affected your relationship with your children?
Are you responsible for administering discipline, or does your spouse handle that?
Does anyone else live in your home? (Name, age, and relationship)
How do you spend your free time?
Any special friends?
Do you get along with your friends as well as before?
How has your current family arrangements changed as a result of the accident?

Legal:

Is your case involved in litigation?
Name of attorney?