Biographical Information (SH) - Adult

 

Referred by:                                                                                                       Date:                    Please answer all of the following questions as specifically and completely as possible.

 

Name:                                                                           DOB: ____/____/_ _____      Gender:  M    F   Other    

Social Security No: ____-____-_____       Driver’s License: ____________________________________________   

 

Home Address:_______________________________________City________________________Zip___________

Home Phone: (         ) ______________Cell Phone: (        )_________________Email:_______________________

 

Marital/Cohabitation Status:_____________________ Religious Preference:_______________________________

Highest Education Obtained __________________________Occupation:_________________________________ 

 

Employer: ______________________________________________Work Phone: (         )____________________

 

Your Parents (names, ages, occupations):___________________________________________________________

____________________________________________________________________________________________

 

Your Siblings (names, ages, occupations): __________________________________________________________

____________________________________________________________________________________________

Significant Other(s)/Spouse/Partner:

                                                                 Relationship                         Social

Name: ____________________________  to you: ______________ Security No: ____-____-______

Date of Birth: ___/___/___                  Home Phone (if different from yours): (          )________________________

 

Highest Education Obtained:______________________Occupation:_____________________________________

Employer: ______________________________________________ Work Phone: (         )____________________

Parents (names, ages, occupations): _______________________________________________________________

 

Siblings (names and ages):_______________________________________________________________________

 

Additional Significant Other(s).  ________________________________________________________________

 

Fill out the following information for each child of both and your partner, children from previous relationships, and adopted children. If neither has children (go to next section). 

B             =              Both of ours, biological child BA          =              Both of ours, adopted (or taken on)

M            =              My biological child                                 MA         =              My child, adopted (or taken on)

P              =              Partner's biological child                       PA             =              Partner's child, adopted (or taken on)

Child's name               Age             Gender                      Whose child?                    Lives with whom?

1)                                                                            F   M                                                      

2)                                                                            F   M                                                      

3)                                                                            F   M                                                      

4)                                                                            F   M                                                      

5)                                                                            F   M                                                      

6)                                                                    F   M

 

Military Service:

Yourself - Branch of Service:______________________________ Dates of Service:_________________________

 

Spouse /Significant Other - Branch of Service: _____________________ Dates of Service:___________________ 

 

Disabled Veteran? If so, are you receiving services from the Veteran's Administration?_______________________

BRIEF MEDICAL HISTORY

Please make check mark by any of the following that may apply to you:

 

__Heart attack if so, how many years ago? ________                                              __Rheumatic Fever

__Heart murmur or Mitral valve prolapse                                                     __Diabetes or abnormal blood-sugar tests

__Chest or heart pain                                                                                         __Racing or fast heart beat

__Diseases of the arteries                                                                                  __High cholesterol

__Aortic stenosis or aneurism                                                                           __Dizziness or fainting spells

__Varicose veins                                                                                                 __Migraine or recurrent headaches?

__Phlebitis (inflammation of a vein)                                                               __Epilepsy or seizures

__Deep vein thrombosis (blood clot)?                                                             __Infectious mononucleosis

__Stroke                                                                                                                __High blood pressure

__Memory Problems                                                                                          __Poor concentration

__Leukemia                                                                                                         __Idiopathic blood diseases             

__Diphtheria                                                                                                        __Scarlet Fever

__Thyroid problems                                                                                           __Jaundice or gall bladder problems

__Anemia                                                                                                             __Diabetes (Type I or Type II) circle

__Pneumonia                                                                                                       __Bronchitis

__Asthma                                                                                                             __Shortness of breath

__Glaucoma or increased pressure in the eyes                                              __Cataract or lens transplant

__Eye conditions such as bleeding in the retina or detached retina

__Stomach or intestinal problems, such as recurrent heartburn, ulcers, constipation or diarrhea

__Significant hearing problems or loss

__Arthritis of legs or arms                                                                                  __Injuries to back, arms, legs or joint

__Back problems                                                                                                                __Swollen or painful knees or ankles

__Broken bones                                                                                                  __Swollen, stiff or painful joints

__Foot problems                                                                                                 __Foot or ankle sores that won’t heal

__Pain in your legs after walking short distances (leg cramps)

__Persistent pain or problems walking after you have fallen

__Cancer: If so, what type_________________________

  • Abnormal chest X-ray
  • Has a doctor ever said that you have or have had heart trouble, an abnormal electrocardiogram (ECG or EKG), heart attack or coronary?

Family of origin Diseases (please place check mark by all that apply):

__Diabetes                                              __ Cancer                                       __High blood pressure

__Asthma or hay fever                        __Pulmonary Disease                   __Congestive Heart Failure

__Heart attacks under age 50                                                                      __Strokes under age 50

__Congenital heart disease (existing at birth but not hereditary)           __Leukemia under age 60

__Heart surgeries                                                             __Lung surgeries

       __Obesity (20 or more pounds overweight)

FOR MEN ONLY          Please answer the following. Do you have or have had:

Prostate problems?                                       Erectile dysfunction?

Difficulty urinating?                                       Low sexual desire?

Sexually transmitted infections (STI's)                        HIV?

Breast cancer?                      Have you been screened for breast cancer? __Yes   or __no

FOR WOMEN ONLY    Please answer the following. Do you have or have had:

Menstrual period problems?                                  Significant childbirth - related problems?

Urine loss when you cough, sneeze or laugh?        Post-partum complications or depression?

Low sexual desire?                                               Painful intercourse?

Breast or ovarian cancer?                                     Pelvic Inflammatory disease?

Sexually transmitted infections (STI's)                   HIV?

 

 

List any other health problems, surgeries, or traumatic injuries or accidents____________________________

 

____________________________________________________________________________________________

 

Number of Pregnancies: ____________________Method of Birth Control: _____________________________

 

When was your last physical examination?_________________________________________________________

 

List ALL Medications you are presently taking (including vitamins, supplements, MEDICAL FOODS):________

 

____________________________________________________________________________________________

 

Have you had any previous therapy or counseling? _____________ If yes, when? __________________________

 

with whom? _______________________________ for what problems?___________________________________

 

Have you had any Psychiatric hospitalizations? If yes, when___________________and where________________?

 

Circle all of the following that describe you and/or your areas of concern:

 

Alcohol                                                 Food - eating too much                                     Hallucinations

Abuse-emotional                Food - eating too little                                       Relationship problems

Abuse-physical                                    Feeling fearful                                                    Relatives

Abuse-sexual                                       Feeling helpless                                                  Sex problems

Anger                                                    Feeling hopeless                                                 Sexual Addiction

Anxiety                                                 Feeling out of control                                       Sleeping too much

Childhood Issues                Feeling threatened                                             Sleeping too little

Conflict with children                       Finances                                                               Stress

Confusion                                             Friends                                                                  Suicidal thoughts

Depression                                           Gender identity/Sexuality                                Violence

Drugs                                                     Grief/loss issues                                                  Weight gain or loss

Flashback Memories                         Guilt                                                                      Work issues        

 

How many alcoholic beverages do you drink per week?   0______1-7 ______8-14______ 15-21______ 22+______

 

Briefly describe your current home life: ____________________________________________________________

 

____________________________________________________________________________________________

 

Briefly describe your current relationships with family members: _______________________________________

 

____________________________________________________________________________________________

 

Briefly describe your current relationships with Friends/coworkers: ______________________________________

 

____________________________________________________________________________________________

How would you describe your sexual orientation?_________________________________________________

Are you comfortable with your gender? Yes: No: Please explain. _____________________________

Is there anything about your sexuality that you wish you could change? _______________________________

Describe your upbringing (ie., liberal, conservative, loving, strict, confusing, pro-sex, anti-sex, bohemian,

religious, etc.) _______________________________________________________________________________

What kind of messages about sex did you receive from your family of origin or care-takers? _______________

_________________________________________________________________________________________

Describe the earliest sexual experience(s) that you can remember. How old were you? ____________________

_________________________________________________________________________________________

How old were you when you first felt sexually attracted to someone? What were the circumstances? _________

_______________________________________________________________________________________

How old were you when you first did any kind of sexual touching with another person? What were the

circumstances? ____________________________________________________________________________

How old were you when you first had sexual intercourse? What were the circumstances? ________________

_________________________________________________________________________________________

How old were you when you had your first orgasm (the first you can remember)? What were the

circumstances? ____________________________________________________________________________

Describe the most significant sexual experience(s) of your childhood and/or adolescence.________________

_________________________________________________________________________________________

Have you ever been forced to have sex when you didn't want to?      Yes:   No: Please describe. _________

_________________________________________________________________________________________

Currently, how many sexual partners do you have? Be approximate, if necessary. _______________________

Approximately how many different sexual partners have you had in your lifetime? ______________________

When you have sex with a partner, about what percentage of the time do you have an orgasm? _____________

When you masturbate, about what percentage of the time do you have an orgasm?_______________________

How frequently do you masturbate?____________________________________________________________

How many minutes do you usually spend masturbating at one time? ______________________________

Do you have a special way or place in which you like to masturbate? Please describe. ____________________

_________________________________________________________________________________________
 Have you ever had sex with a sex worker (masseuse, prostitute, dominatrix)? Yes: No: Please

describe. _________________________________________________________________________________

Have you ever been arrested because of your sexual behavior? Yes: No:  If yes, what were you arrested

for? _____________________________________________________________________________________

What do you feel are your main sexual "assets"? (ie., looks, charm, warmth, humor, intelligence, wealth...) __

_________________________________________________________________________________________

_________________________________________________________________________________________

What does the word "pleasure" mean to you? What gives you pleasure? Be as general or specific as you like. _

_________________________________________________________________________________________

_________________________________________________________________________________________

What are the best aspects of your relationship? Be as general or specific as you like. _____________________

_________________________________________________________________________________________

_________________________________________________________________________________________


Is there anything else about yourself, your sexuality, your goals or your fantasies that you'd like to add? ______

_________________________________________________________________________________________

_________________________________________________________________________________________

What else do you think the therapist should know about you?

 

____________________________________________________________________________________________

 

___________________________________________________________________________________________