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Your Visit
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Child and Adolescent Personal History Questionnaire

Today's Date*
Date of Assessment*
Clinical ID #
Client Name*
First Last
Date of Birth*
Current Age*
Sex*
- Male
- Female
Name of Person Completing Form*
First Last
Phone*
Email
Enter Email Confirm Email

Legal Guardian(s)*

First Name	Last Name	Email Address

Are there any custody or visitation agreements?*
- Yes
- No
Please explain:*
Referral Source
Referral Source
- Community Provider
- County
- Family/Friend
- Law Enforcement
- Medical Facility
- School/College
Community Providers
County
Family/Friend
Law Enforcement
Medical Facility
School/College
Assessment Overview
Presenting Problem(s)/Reason for Assessment*
Please provide examples of behaviors that you are concerned about.
When did the problems begin?*
What have you already done to help with the problems?*
Are there, or have there been, other professionals involved in the client's care?*
- Yes
- No
Select all that apply:*
Please list any other professionals:*
Please describe what services were provided or offered:*
Please select the symptom(s) the client is currently displaying:*
(select all that apply)
What areas have been impaired by the symptoms listed above:*
(select all that apply)
Please list any other areas that have been impaired:*
Chemical Use History
Has the client ever used tobacco?*
- Yes
- No
Please describe the tobacco use:*
Does the client drink alcohol or use drugs?*
- Yes
- No
What was the age of first use?*
What is typically used and how much?*
Has anyone been concerned by the client's chemical use?*
- Yes
- No
Please explain.*
Have there been any negative consequences or treatment involvement?*
- Yes
- No
Please explain.*
Has gambling ever been a concern and/or caused problems?*
- Yes
- No
Please explain.*
Please describe the family history of addictions or chemical dependency:*
Medical History
Who is the client's healthcare provider?
When was the client's last physical exam?
Describe any current medical problems or physical symptoms the client is having:

List any medications the client is taking:

Name of Medication	Dosage (if known)	Reason for use (if known)

Please list any important medical information (illnesses, injuries, surgeries, drug side effects, etc.):
Does the client have any allergies?*
- Yes
- No
Please list all known allergies:*
Has the client ever been hit in the head, or suffered head or brain trauma or injury?*
- Yes
- No
Please explain:
Mental Health History
Has the client had thoughts or actions of suicide or self-harm? Or harming another person?*
- Yes
- No
Please explain:
List the client's strengths and vulnerabilities:*
List the client's triggers and warning signs for relapse:*

Please list previous mental health services (include therapy, psychiatry, hospitalizations, commitments, county services, etc):

Date of service	Where the client was seen/treated	Focus of treatment

List current and previous medications that have been prescribed for mental health or psychiatric reasons:

Medication	Dosage (if known)	Reason for use (if known)

Social/Relationship History
Has the client begun to date?*
- Yes
- No
How old was the client?*
Have these relationships been healthy, or has there been any maltreatment and/or abuse?*
Is the client sexually active?*
- Yes
- No
Does the client have children?*
- Yes
- No

Please provide name(s) and age(s)*

Name	Age

Describe the client's interests:
(time with friends, hobbies, sports, etc.)
Please list any spiritual or cultural considerations you would like us to be aware of:
What are the client's coping skills?
Education/Work History
What school does the client attend?*
Current grade:*
Describe the client's school experience:*
(Please be specific and include how many schools the client has attended, academic progress, social involvement, extra-curricular involvement, getting along with teachers and peers, etc.)
Have there been any difficulties in school?*
(Please include in/out of school suspensions, expulsions, truancy, or other academic issues)
Does the client have an Individualized Education Plan (IEP)?*
- Yes
- No
Please describe the special needs and services provided.*
Please bring a copy of the plan to the client's appointment.
Is there a family history of family academic problems or concerns?*
- Yes
- No
Please describe:*
Legal History
Does the client have any past or current legal problems?*
- Yes
- No
For what? Please provide name of Probation Officer, if applicable.*
Has the client been ordered by court/probation for assessment, to attend therapy or treatment?*
- Yes
- No
Family History
Where was the client born and where has the client lived since?*
What has growing up been like for the client?*
Has the client been exposed to violence in the family or elsewhere (verbal, emotional, sexual, physical)?*
- Yes
- No
Please explain:*
Has the client been abused, neglected, or maltreated by anyone?*
- Yes
- No
Please explain what happened:*

Please complete the following information about significant caregivers the client has lived with: (parents, step, grand, or foster-parents, etc.)*

Name	Relationship	Age	Occupation	Alive? (Yes/No)

Are the client's parents divorced?*
- Yes
- No
How old was the client at the time of the divorce?*

Please complete the following information about sibling, step-siblings, or half-siblings:*

Name	Relationship	Age	Occupation	Alive? (Yes/No)

Who currently lives in the home with the client?*

Name	Relationship

Please describe the current relationships with the parents / caregivers / siblings:*
Have any family members been treated for or diagnosed with a mental illness?*
- Yes
- No
Please explain:*
Has the client known anyone that committed suicide?*
- Yes
- No
Please explain:*
Are you aware of any developmental problems or concerns from pregnancy / birth / childhood / adolescence? Was there the potential for maternal chemical use during pregnancy?*
At about what age did the client complete the following?
(mark NA if not yet obtained)
Walk alone:*
Complete toilet training:*
Speak in sentences:*
Sleep through the night:*
Discontinue bed wetting:*
Other:*
Have there been any concerns about the client meeting these developmental milestones or any others?*
Coordination of Care
Please list any other service providers that are assisting the client:
Please give any additional information that may be important or beneficial in treating the client:
What do you enjoy most about the client? Or as the client, what makes you a special or unique person?*
Email
This field is for validation purposes and should be left unchanged.

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Zumbro Valley Health Center