Bayside Therapy Associates Adult Intake Form Page 3
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4Check any of the conditions you have had and the date of onset:
Condition
Date
Condition
Date
Condition
Date
Condition
Date
ADD/ADHD
Autism
Hypoglycemia
Stomach Ulcer
AIDS/HIV
Panic Attacks
Thyroid Problem
Bipolar Disorder
Allergies
Cancer
Skin Problem
Obsessive/Compulsive
Alzheimer’s/Dementia
Cutting
Learning Disability
Other:
Anemia
Depression
Low Blood Pressure
Anger Problems
Diabetes
High Blood Pressure
Anxiety
Eating Disorder
Obesity
Arthritis
Head Trauma
Migraine
Asthma
Heart Disease
Seizure Disorder
Is there a history of any of the following in your family:
Alcoholism
Birth Defects
Mental Retardation
Cancer
Obsessive/Compulsive
Alzheimer’s Disease/Dementia
Panic Disorder
Depression
Anger Problems
Anxiety Disorder
Diabetes
Schizophrenia
Drug Abuse
Seizure Disorder
ADD/ADHD
Behavior Problems
Heart Disease
Suicide/Homicide
Bipolar Disorder
High Blood Pressure
Thyroid Problem
Aspergers/Autism
Violent/Abusive Behavior
Describe Any Hospitalization, Surgeries or Accidents
Date: ____________________
Age: __________
Reason: ______________________________________________
Date: ____________________
Age: __________
Reason: ______________________________________________
Date: ____________________
Age: __________
Reason: _______________________________________________
)
SOCIAL-ECONOMIC HISTORY: (check all that apply for client
Marital Status:
Employment:
Financial Situation
Single, Never Married
Employed and Satisfied
No Current Financial
Engaged _______ Months
Employed but Dissatisfied
Problems
Married _______ Years
Unemployed
Impulsive Spending
Divorced ________ Years
Coworker Conflict
Current Legal Issues
Separated ________ Years
Supervisor Conflict
Poverty or Below-Poverty
Divorce in Process
Unstable Work History
Income
Live-in for ________ Years
Disabled: _____________
Large Debt
Widowed ________ Years
Retired
(3)
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Parent category: Business