Background History Form

If you wish to download a PDF file of this form to print and complete by hand, click here.

Step 1

We have learned that it is hard to remember everything you want to tell us when you are sitting in our offce. We want to know as much as we can about your concerns and living circumstances, and have found that asking many of our questions ahead of your visit makes it easier for everyone involved. Please answer the following questions to the best of your ability. Some of the items will probably not apply to your situation, however we live in diverse world and hope to not overlook possibilities. The more you tell us, the better the job we can do to address your concerns. If a section of the questionnaire doesn’t apply to you (for example occupational history for a child), or if you prefer to not answer any questions that's ok - just skip to the next one!

Patient/Primary Client's Information

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Please provide us with appropriate email addresses- we will never share them with others without your permission

Step 2

Information regarding important persons in the primary patient's life

Please provide us with additional contact information of important persons in the primary patient's life - we will never share them with others without your permission



Step 3

Please list your concerns and reasons for seeking services








Step 4

Current Status of Patient







  Not at all Somewhat A Lot
Fidgets
Difficulty remaining seated
Difficulty playing quietly
Often talks excessively
Runs about or climbs excessively
On the go or acts as if driven by a motor
Difficulty awaiting turn
Often blurts out answers to questions before completed
Often interrupts or intrudes on others
Often engages in physically dangerous activities
Difficulty following instructions
Difficulty sustaining attention
Shifts from one activity to another
Often does not listen
Often loses things
Easily distracted
Gives up easily
Inconsistent performance
Poor motivation
Disorganized
Doesn’t finish tasks
Low frustration tolerance
Poor handwriting
Mood swings
Often loses temper
Often argues with adults
Often actively defies or refuses adult requests or rules
Often deliberately does things that annoy other people
Often blames others for own mistakes
Is often touchy or easily annoyed by others
Is often angry or resentful
Is often spiteful or vindictive
Often swears or uses obscene language
Depressed or irritable mood most of day, nearly every day
Diminished pleasure in activities
Agitation or sluggishness
Feelings of worthlessness or excessive inappropriate guilt
Poor appetite or overeating
Trouble sleeping or sleeps too much
Low self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness
Repeated unusual movements
Odd postures
Excessive reaction to noise or fails to react to loud noises
Overreacts to touch
Compulsive rituals
Motor tics
Vocal tics
Can’t get to the point, loses train of thought
Bizarre ideas (e.g., odd fascinations, strange ideas, hallucinations)
Disoriented, confused, staring, or “Spacy”
Incoherent speech (mumbles, uses words only child understands)
Excessive mood swings
Explosive temper with minimal provocation
Excessive clinging, attachment, or dependence on adults
Unusual fears, repetitive worries
Panic attacks
Excessively monotonous or bland affect
Situationally inappropriate emotions
Little or no interest in peers or friends
Significant indiscreet remarks
Initiates or terminates interactions inappropriately
Abnormal social behavior
Excessive reaction to changes in routine

Step 5

Early History

The following questions help us to understand the patient's growth and development, which is sometimes useful in understanding their current situation. Many of the items may not apply, or may be hard to remember, but please give us as much information as you can!

Time Score
1 minute
5 minutes
10 minutes

Please describe you child’s temperament:
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Sitting Crawling Walking Well-coordinated
Self-feeding Scribbling Tied shoes Babbling
First words Sentences Good use of language Toileting during the day
Toileting at night

Step 6

Educational history






Step 7

Health information and history





























# Medication Dosage For what reason
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Vision trouble






Hearing trouble


Other sensory trouble

Movement difficulty




Ongoing medical illness associated with:


























































What substances has the patient either previously or currently used:
















Step 8

Family Arrangement

Person # Name Age Relationship to primary patient
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Step 9

Parents History

Birth Mother Birth Father
Age
Highest grade completed/degree
Occupation
Special Education
Repeated a grade
Learning Disability
Attention-Deficit/Hyperactivity Disorder
Speech/Language difficulty
Psychiatric history
Nonbiological caregiver #1 Nonbiological caregiver #2
Age
Highest grade completed/degree
Occupation
Special Education
Repeated a grade
Learning Disability
Attention-Deficit/Hyperactivity Disorder
Speech/Language difficulty
Psychiatric history
(including step-siblings and half-siblings)
Name Age M/F Living at home? School/behavioral/health problems?

Step 10

Occupational history

Step 11

Military history