Client name
Client ID#
Client SS#
Page 1
Date
BIOPSYCHOSOCIAL HISTORY
PRESENTING PROBLEMS
Presenting problems
Duration (months)
Additional information:
CURRENT SYMPTOM CHECKLIST (Rate intensity of symptoms currently present)
None  This symptom not present at this time • Mild  Impacts quality of life, but no significant impairment of day-to-day functioning
Moderate  Significant impact on quality of life and/or day-to-day functioning • Severe  Profound impact on quality of life and/or day-to-day functioning
None
Mild
Moderate
Severe
None
Mild
Moderate
Severe
None
Mild
Moderate Severe
depressed mood
[ ]
[ ]
[ ]
[ ]
bingeing/purging
[ ]
[ ]
[ ]
[ ]
guilt
[ ]
[ ]
[ ]
[ ]
appetite disturbance
[ ]
[ ]
[ ]
[ ]
laxative/diuretic abuse
[ ]
[ ]
[ ]
[ ]
elevated mood
[ ]
[ ]
[ ]
[ ]
sleep disturbance
[ ]
[ ]
[ ]
[ ]
anorexia
[ ]
[ ]
[ ]
[ ]
hyperactivity
[ ]
[ ]
[ ]
[ ]
elimination disturbance
[ ]
[ ]
[ ]
[ ]
paranoid ideation
[ ]
[ ]
[ ]
[ ]
dissociative states
[ ]
[ ]
[ ]
[ ]
fatigue/low energy
[ ]
[ ]
[ ]
[ ]
circumstantial symptoms [ ]
[ ]
[ ]
[ ]
somatic complaints
[ ]
[ ]
[ ]
[ ]
psychomotor retardation
[ ]
[ ]
[ ]
[ ]
loose associations
[ ]
[ ]
[ ]
[ ]
self-mutilation
[ ]
[ ]
[ ]
[ ]
poor concentration
[ ]
[ ]
[ ]
[ ]
delusions
[ ]
[ ]
[ ]
[ ]
significant weight gain/loss
[ ]
[ ]
[ ]
[ ]
poor grooming
[ ]
[ ]
[ ]
[ ]
hallucinations
[ ]
[ ]
[ ]
[ ]
concomitant medical condition [ ]
[ ]
[ ]
[ ]
mood swings
[ ]
[ ]
[ ]
[ ]
aggressive behaviors
[ ]
[ ]
[ ]
[ ]
emotional trauma victim
[ ]
[ ]
[ ]
[ ]
agitation
[ ]
[ ]
[ ]
[ ]
conduct problems
[ ]
[ ]
[ ]
[ ]
physical trauma victim
[ ]
[ ]
[ ]
[ ]
emotionality
[ ]
[ ]
[ ]
[ ]
oppositional behavior
[ ]
[ ]
[ ]
[ ]
sexual trauma victim
[ ]
[ ]
[ ]
[ ]
irritability
[ ]
[ ]
[ ]
[ ]
sexual dysfunction
[ ]
[ ]
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[ ]
emotional trauma perpetrator
[ ]
[ ]
[ ]
[ ]
generalized anxiety
[ ]
[ ]
[ ]
[ ]
grief
[ ]
[ ]
[ ]
[ ]
physical trauma perpetrator
[ ]
[ ]
[ ]
[ ]
panic attacks
[ ]
[ ]
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[ ]
hopelessness
[ ]
[ ]
[ ]
[ ]
sexual trauma perpetrator
[ ]
[ ]
[ ]
[ ]
phobias
[ ]
[ ]
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[ ]
social isolation
[ ]
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[ ]
substance abuse
[ ]
[ ]
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obsessions/compulsions
[ ]
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worthlessness
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other (specify)
[ ]
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[ ]
[ ]
EMOTIONAL/PSYCHIATRIC HISTORY
[ ] [ ] Prior outpatient psychotherapy?
No Yes If yes, on
occasions. Longest treatment by
for
sessions from
Provider Name
Prior provider name
City
State
Phone
/
to
Month/Year
Diagnosis
/
Month/Year
Intervention/Modality
Beneficial?
[ ] [ ] Has any family member had outpatient psychotherapy? If yes, who/why (list all):
No Yes
[ ] [ ] Prior inpatient treatment for a psychiatric, emotional, or substance use disorder?
No Yes If yes, on
occasions. Longest treatment at
Name of facility
Inpatient facility name
City
State
Phone
from
/
to
Month/Year
Diagnosis
Intervention/Modality
/
Month/Year
Beneficial?
[ ] [ ] Has any family member had inpatient treatment for a psychiatric, emotional, or substance use disorder? If yes,
No Yes who/why (list all):
[ ] [ ] Prior or current psychotropic medication usage? If yes:
No Yes Medication
Dosage
Frequency Start date End date Physician
Side effects
Beneficial?
Client name
Client ID#
Client SS#
Page 2
Date
[ ] [ ] Has any family member used psychotropic medications? If yes, who/what/why (list all):
No Yes
FAMILY HISTORY
FAMILY OF ORIGIN
Present during childhood:
Present
entire
childhood
mother
[ ]
father
[ ]
stepmother
[ ]
stepfather
[ ]
brother(s)
[ ]
sister(s)
[ ]
other (specify)
[ ]
Present
part of
childhood
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
Not
present
at all
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
Age of emancipation from home:
Parents' current marital status:
[ ] married to each other
[ ] separated for
years
[ ] divorced for
years
[ ] mother remarried
times
[ ] father remarried
times
[ ] mother involved with someone
[ ] father involved with someone
[ ] mother deceased for
years
age of patient at mother's death
[ ] father deceased for
years
age of patient at father's death
Describe parents:
Father
full name
occupation
education
general health
Mother
Describe childhood family experience:
[ ] outstanding home environment
[ ] normal home environment
[ ] chaotic home environment
[ ] witnessed physical/verbal/sexual abuse toward others
[ ] experienced physical/verbal/sexual abuse from others
Circumstances:
Special circumstances in childhood:
IMMEDIATE FAMILY
Marital status:
[ ] single, never married
[ ] engaged
months
[ ] married for
years
[ ] divorced for
years
[ ] separated for
years
[ ] divorce in process
months
[ ] live-in for
years
[ ]
prior marriages (self)
[ ]
prior marriages (partner)
Intimate relationship:
[ ] never been in a serious relationship
[ ] not currently in relationship
[ ] currently in a serious relationship
List all persons currently living in patient's household:
Name
Age Sex
Relationship to patient
Relationship satisfaction:
[ ] very satisfied with relationship
[ ] satisfied with relationship
[ ] somewhat satisfied with relationship
[ ] dissatisfied with relationship
[ ] very dissatisfied with relationship
List children not living in same household as patient:
Frequency of visitation of above:
Describe any past or current significant issues in intimate relationships:
Describe any past or current significant issues in other immediate family relationships:
MEDICAL HISTORY (check all that apply for client)
Describe current physical health: [ ] Good [ ] Fair [ ] Poor
List name of primary care physician:
Name
Phone
List name of psychiatrist: (if any):
Name
Phone
Is there a history of any of the following in the family:
[ ] tuberculosis
[ ] heart disease
[ ] birth defects
[ ] high blood pressure
[ ] emotional problems
[ ] alcoholism
[ ] behavior problems
[ ] drug abuse
[ ] thyroid problems
[ ] diabetes
[ ] cancer
[ ] Alzheimer's disease/dementia
[ ] mental retardation
[ ] stroke
Client name
Client ID#
Client SS#
List any medications currently being taken (give dosage & reason):
Date
Page 3
[ ] other chronic or serious health problems
Describe any serious hospitalization or accidents:
Date
Age
Reason
Date
Age
Reason
Date:
Age
Reason
List any known allergies:
List any abnormal lab test results:
Date
Result
Date
Result
PREGNANCY AND CHILDBIRTH
What type of childbirth did you have?
_______________________________________________________________________________________________
How much did your baby weigh at birth?
_____________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_
What was your reaction when you find out you were pregnant? ___________________________________________________________________________
_____________________________________________________________________________________________________________________________
_
Did it take longer than a year to conceive?
____________________________________________________________________________________________
Did you receive infertility treatment?
________________________________________________________________________________________________
Any miscarriages or stillbirths?
_____________________________________________________________________________________________________
Any abortions?
_________________________________________________________________________________________________________________
Was there anything outstanding or remarkable from your pregnancy? ______________________________________________________________________
_____________________________________________________________________________________________________________________________
_
Did you enjoy being pregnant?
_____________________________________________________________________________________________________
What was your greatest fear during pregnancy?
________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_
Did your baby have any significant health problems at birth? _____________________________________________________________________________
_____________________________________________________________________________________________________________________________
_
Did you have any significant problems related to childbirth?
_____________________________________________________________________________
_____________________________________________________________________________________________________________________________
_
SUBSTANCE USE HISTORY (check all that apply for client)
Family alcohol/drug abuse history:
Substances used:
(complete all that apply)
[
[
[
[
[
] father
] mother
] grandparent(s)
] sibling(s)
] other
[
[
[
[
] stepparent/live-in
] uncle(s)/aunt(s)
] spouse/significant other
] children
Substance use status:
[
[
[
[
[
[
] no history of abuse
] active abuse
] early full remission
] early partial remission
] sustained full remission
] sustained partial remission
[
[
[
[
[
[
[
[
[
[
[
[
[
] alcohol
] amphetamines/speed
] barbiturates/owners
] caffeine
] cocaine
] crack cocaine
] hallucinogens (e.g., LSD)
] inhalants (e.g., glue, gas)
] marijuana or hashish
] nicotine/cigarettes
] PCP
] prescription
] other
First use age
Current Use
Last use age (Yes/No) Frequency Amount
Client name
Client ID#
Treatment history:
[
[
[
[
[
Client SS#
Page 4
Date
Consequences of substance abuse (check all that apply):
] outpatient (age[s]
] inpatient (age[s]
] 12-step program (age[s]
] stopped on own (age[s]
] other (age[s]
describe:
)
)
)
)
[
[
[
[
[
] hangovers
] seizures
] blackouts
] overdose
] other
[
[
[
[
] withdrawal symptoms
] medical conditions
] tolerance changes
] loss of control amount used
[
[
[
[
] sleep disturbance
] assaults
] suicidal impulse
] relationship conflicts
[ ] binges
[ ] job loss
[ ] arrests
DEVELOPMENTAL HISTORY (check all that apply for a child/adolescent client)
Problems during
mother's pregnancy:
[
[
[
[
[
[
[
[
[
[
] none
] high blood pressure
] kidney infection
] German measles
] emotional stress
] bleeding
] alcohol use
] drug use
] cigarette use
] other
Birth:
[ ] normal delivery
[ ] difficult delivery
[ ] cesarean delivery
[ ] complications
Childhood health:
[ ] chickenpox (age
)
[ ] German measles (age
)
[ ] red measles (age
)
[ ] rheumatic fever (age
)
[ ] whooping cough (age
)
birth weight
lbs
oz. [ ] scarlet fever (age
)
[ ] autism
Infancy:
[ ] ear infections
[ ] feeding problems
[ ] allergies to
[ ] sleep problems
[ ] significant injuries
[ ] toilet training problems
[ ] chronic, serious health problems
Delayed developmental milestones (check only
those milestones that did not occur at expected age):
[
[
[
[
[
[
[
[
[
] sitting
] rolling over
] standing
] walking
] feeding self
] speaking words
] speaking sentences
] controlling bladder
] other
[
[
[
[
[
[
[
[
] controlling bowels
] sleeping alone
] dressing self
] engaging peers
] tolerating separation
] playing cooperatively
] riding tricycle
] riding bicycle
[
[
[
[
[
[
[
[
] lead poising (age
] mumps (age
] diphtheria (age
] poliomyelitis (age
] pneumonia (age
] tuberculosis (age
] mental retardation
] asthma
Emotional / behavior problems (check all that apply):
[
[
[
[
[
[
[
[
[
[
] drug use
] alcohol abuse
] chronic lying
] stealing
] violent temper
] fire-setting
] hyperactive
] animal cruelty
] assaults others
] disobedient
[
[
[
[
[
[
[
[
[
] repeats words of others
] not trustworthy
] hostile/angry mood
] indecisive
] immature
] bizarre behavior
] self-injurious threats
] frequently tearful
] frequently daydreams
[ ] lack of attachment
[
[
[
[
[
[
[
[
[
] distrustful
] extreme worrier
] self-injurious acts
] impulsive
] easily distracted
] poor concentration
] often sad
] breaks things
] other
_________________
Social interaction (check all that apply):
Intellectual / academic functioning (check all that apply):
[
[
[
[
[ ] normal intelligence
[ ] authority conflicts
[ ] high intelligence
[ ] attention problems
[ ] learning problems
[ ] underachieving
Current or highest education level
] normal social interaction
] isolates self
] very shy
] alienates self
[
[
[
[
)
)
)
)
)
)
] inappropriate sex play
] dominates others
] associates with acting-out peers
] other
[ ] mild retardation
[ ] moderate retardation
[ ] severe retardation
Describe any other developmental problems or issues:
SOCIO-ECONOMIC HISTORY (check all that apply for client)
Living situation:
[ ] housing adequate
[ ] homeless
[ ] housing overcrowded
[ ] dependent on others for housing
[ ] housing dangerous/deteriorating
[ ] living companions dysfunctional
Social support system:
[ ] supportive network
[ ] few friends
[ ] substance-use-based friends
[ ] no friends
[ ] distant from family of origin
Sexual history:
[ ] heterosexual orientation
[ ] homosexual orientation
[ ] bisexual orientation
[ ] currently sexually active
[ ] currently sexually satisfied
Additional information:
[
[
[
[
[
] currently sexually dissatisfied
] age first sex experience
] age first pregnancy/fatherhood
] history of promiscuity age
to
] history of unsafe sex age to
Military history:
Employment:
[ ] employed and satisfied
[ ] never in military
[ ] served in military - no incident
Cultural/spiritual/recreational history:
cultural identity (e.g., ethnicity, religion):
Client name
[
[
[
[
[
[
] employed but dissatisfied
] unemployed
] coworker conflicts
] supervisor conflicts
] unstable work history
] disabled:
Financial situation:
[ ] no current financial problems
[ ] large indebtedness
[ ] poverty or below-poverty income
[ ] impulsive spending
[ ] relationship conflicts over finances
Client ID#
Client SS#
Date
Page 5
[ ] served in military - with incident
describe any cultural issues that contribute to current problem:
Legal history:
[ ] no legal problems
[ ] now on parole/probation
[ ] arrest(s) not substance-related
[ ] arrest(s) substance-related
[ ] court ordered this treatment
[ ] jail/prison
time(s)
total time served:
describe last legal difficulty:
currently active in community/recreational activities? Yes [
formerly active in community/recreational activities? Yes [
currently engage in hobbies?
Yes [
currently participate in spiritual activities?
Yes [
if answered "yes" to any of above, describe:
SOURCES OF DATA PROVIDED ABOVE: [ ] Client self-report for all [ ] A variety of sources (if so, check appropriate sources
below):
Presenting Problems/Symptoms
[ ] client self-report
[ ] client’s parent/guardian
[ ] other (specify)
Family History
[ ] client self-report
[ ] cleints parent/guardian
[ ] other (specify)
Developmental History
[ ] client self-report
[ ] client's parent/guardian
[ ] other (specify)
Emotional/Psychiatric History
[ ] client self-report
[ ] client’s parent/guardian
[ ] other (specify)
Medical/Substance Use History
[ ] client self-report
[ ] client's parent/guardian
[ ] other (specify)
Socioeconomic History
[ ] client self-report
[ ] client's parent/guardian
[ ] other (specify)
] No [
] No [
] No [
] No [
]
]
]
]