ADULT HISTORY QUESTIONNAIRE
The purpose of this questionnaire is to obtain an understanding of your life experience
and background. Then we can begin to develop a comprehensive treatment program
suited to your specific needs. Please return this questionnaire when completed, or at
your scheduled appointment.
Name of Client: ______________________________ Circle: M / F
Today’s Date:____________
Birth Date: ______________________ Age:__________
Mailing address:__________________________________________
City:_____________________ State: _______ Zip: _____________
By who were you referred?
________________________________________________________________
Chief Complaint:
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
What made you seek help at this time?
_______________________________________________________________________
Any previous mental health contact? Please explain.
What changes would you like to see in your life?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
________________________________________________
Page 1 of 11
Kym Spring Thompson, PsyD, LLC  950 South Cherry Street Suite 704 Denver Colorado 80246 
ph: 720.295.5437  fax: 303.504.4286  doctorkym.com  kspringthompson@gmail.com
PRESENTING PROBLEM:
(check all that apply)
____Very unhappy
____Irritable
____Temper Outbursts
____Withdrawn
____Daydreaming
____Fearful
____Clumsy
____Overactive
____Slow
____Short attention span
____Distractible
____Lack initiative
____Undependable
____Conflicts with others
____Phobic
____Impulsive
_____Stubborn
_____Disobedient
_____Mean to others
_____Destructive
_____Trouble with the
law
_____Running away
_____Self-mutilating
_____Head banging
_____Shy
_____Rocking
_____Strange behavior
_____Strange thoughts
_____Fire setting
_____Stealing
_____Lying
_____Sexual trouble
_____School difficulty
_____Eating problems
_____Sleeping problems
_____Drug use
_____Alcohol use
_____Suicide thoughts
_____ Suicidal plan
_____ Suicidal behavior
Others:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Problems perceived to be:
_______very serious ________serious ________not serious
How long have these problems occurred? (number of weeks, months,
years)?_________________________________
PSYCHOSOCIAL HISTORY
How do you identify spiritually, ethnically and culturally?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Page 2 of 11
Kym Spring Thompson, PsyD, LLC  950 South Cherry Street Suite 704 Denver Colorado 80246 
ph: 720.295.5437  fax: 303.504.4286  doctorkym.com  kspringthompson@gmail.com
________________________________________________________________________
________________________________________________________________________
What would you like to change in your interpersonal relationships?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Your relationship status (all that currently apply):
Married
Partnered
Divorced
Remarried
Partner deceased
Separated
Single
CURRENT PARTNER INFORMATION:
Name:____________________ Age: ______
(Please circle one.) Natural parent
Step parent
Adoptive
Relative
Occupation:_____________________
Education:____________________
Religion: ______________________
Birthplace:____________________
Do you have children?
NAME
AGE
GENDER
DO THEY LIVE IN
YOUR HOME?
Status of Your Parents:
MOTHER: Name:____________________ Age: ______
(Please circle one.) Natural parent
Step parent Adoptive
Relative
Page 3 of 11
Kym Spring Thompson, PsyD, LLC  950 South Cherry Street Suite 704 Denver Colorado 80246 
ph: 720.295.5437  fax: 303.504.4286  doctorkym.com  kspringthompson@gmail.com
Occupation:_____________________
Education:____________________
Religion: ______________________
Birthplace:____________________
(Please circle one.)
Married
Divorced
Remarried
Separated
Deceased
Single
FATHER:
Name:____________________ Age: ______
(Please circle one.) Natural parent
Step parent Adoptive
Occupation:_____________________
Relative
Education:____________________
Religion: ______________________
Birthplace:____________________
(Please circle one.)
Married
Divorced
Remarried
Separated
Deceased
Single
OTHER PRIMARY CAREGIVER:
Name:____________________ Age: ______
(Please circle one.) Natural parent
Step parent
Occupation:_____________________
Adoptive
Relative
Education:____________________
Religion: ______________________
Birthplace:____________________
(Please circle one.)
Married
Divorced
Remarried
Separated
Deceased
Single
OTHER PRIMARY CAREGIVER:
Name:____________________ Age: ______
(Please circle one.) Natural parent
Step parent
Occupation:_____________________
Adoptive
Relative
Education:____________________
Religion: ______________________
Birthplace:____________________
(Please circle one.)
Married
Divorced
Remarried
Separated
Deceased
Single
As a child, were you ever placed, boarded, or lived away from your family?
____Yes ____No
Page 4 of 11
Kym Spring Thompson, PsyD, LLC  950 South Cherry Street Suite 704 Denver Colorado 80246 
ph: 720.295.5437  fax: 303.504.4286  doctorkym.com  kspringthompson@gmail.com
Explain:
______________________________________________________________________________
__________________________________________________________________
Significant Deaths or losses in your family:
Name: ________________________
Date of the loss:___________
Relationship to you: __________________________________
What are the major stressors at the present time, if any?
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
List all extended family members by their relation who have drug and/or alcohol
problems (legal or illegal), history of depression, self-destructive behavior, or legal
problems.
Name
Problem
Relation to you
HEALTH INFORMATION:
Page 5 of 11
Kym Spring Thompson, PsyD, LLC  950 South Cherry Street Suite 704 Denver Colorado 80246 
ph: 720.295.5437  fax: 303.504.4286  doctorkym.com  kspringthompson@gmail.com
Name of Primary Care Physician:____________________________________
Phone: ______________________
Are you taking any prescribed medications? If yes, please list name, dosage, explain.
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
Please list any allergies:
______________________________________________________________________________
__________________________________________________________________
Have you ever been hospitalized?
Age/ duration
Problem/ reason
Have you experienced any of the following? If yes, list age and details below:
____ Dental Problem
____ Weight Problems
____ Allergies
____ Skin Problems
____ Asthma
____ Headaches
____ Blood Pressure
____ Meningitis
____ Convulsions
____ Fainting
____ Sinus Problems
____ Visions Prob.
____ Tonsils Out
____ Hyperactivity
____ High fevers
____ Pneumonia
____ Flu
____ Encephalitis
____ Earaches
____ Unconsciousness
____ Stomach Problems
____ Concussions
____ Accident Prone
Page 6 of 11
Kym Spring Thompson, PsyD, LLC  950 South Cherry Street Suite 704 Denver Colorado 80246 
ph: 720.295.5437  fax: 303.504.4286  doctorkym.com  kspringthompson@gmail.com
____ Anemia
____ Head Injury
____ Dizziness
Age/ duration
____ Heart Problems
____ Hearing Prob.
____Other Illnesses, etc
Problem/ reason
Please list any substances you have used:
Substance
Date last used
How much
used
How often
used
Do you feel
this is a
concern?
Are there any family members with chronic or severe medical problems? If yes,
please indicate relative and illness.
Page 7 of 11
Kym Spring Thompson, PsyD, LLC  950 South Cherry Street Suite 704 Denver Colorado 80246 
ph: 720.295.5437  fax: 303.504.4286  doctorkym.com  kspringthompson@gmail.com
Name
Problem
Relation to child
DEVELOPMENTAL HISTORY:
Place of Birth:_______________________________
DEVELOPMENTAL MILESTONES:
Met at appropriate ages: ______yes ________ no
If no explain:
Age/ duration
Problem/ reason
Intervention Received/ dates
EARLY SOCIAL DEVELOPMENT:
How would you describe your relationships with peers:
____ individual play
____ group play
____ cooperative
____ competitive
____ a follower
____ leader
Page 8 of 11
Kym Spring Thompson, PsyD, LLC  950 South Cherry Street Suite 704 Denver Colorado 80246 
ph: 720.295.5437  fax: 303.504.4286  doctorkym.com  kspringthompson@gmail.com
Describe special habits, fears, or idiosyncrasies you had as a child:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
EDUCATIONAL HISTORY:
Childhood Educational History:
Types of classes: ____ Mainstream _____ Special Education,
explain:__________
Did you have an IEP?_____________________________________________
Did you skip a grade? ___No ___ If yes, grade______
Repeat grade? ___ No ____If yes, grade _______
Did you attend school on a regular basis? ___ Yes ___ No
Were you ever suspended or expelled? ___ No ___ If yes, for what?
________________________________________________________________________
________________________________________________________
Highest grade on last report card?_____________ Lowest?____________
Favorite subject?___________Least favorite subject?_________________
Were you motivated for school? Yes / No
Did you participate in extracurricular activities? ____No ; ____Yes, list:
________________________________________________________________________
________________________________________________________________________
________________________________________________
How many friends did you have in school: _____a lot _____ a few ____none
What is your highest completed educational level:
Page 9 of 11
Kym Spring Thompson, PsyD, LLC  950 South Cherry Street Suite 704 Denver Colorado 80246 
ph: 720.295.5437  fax: 303.504.4286  doctorkym.com  kspringthompson@gmail.com
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Do you work? Explain:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
List your special interests, hobbies, skills:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Have you ever been involved with the legal system? ____ No ____ Yes (if yes,
explain)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Additional Comments or Pertinent Information
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_____________________________________________________
Signature of adult client
_______________________
Date
Page 10 of 11
Kym Spring Thompson, PsyD, LLC  950 South Cherry Street Suite 704 Denver Colorado 80246 
ph: 720.295.5437  fax: 303.504.4286  doctorkym.com  kspringthompson@gmail.com
Page 11 of 11
Kym Spring Thompson, PsyD, LLC  950 South Cherry Street Suite 704 Denver Colorado 80246 
ph: 720.295.5437  fax: 303.504.4286  doctorkym.com  kspringthompson@gmail.com