KARNER PSYCHOLOGICAL ASSOCIATES SELF-REPORT PATIENT HISTORY
PATIENT:_________________________________________
TODAY’S
DATE:_______________
PRESENTING PROBLEM(S): (PLEASE DESCRIBE YOUR REASONS
FOR SEEKING COUNSELING AT THIS TIME)
Was there an
event that made these issues or problems surface? If yes, please describe:
PRESENTING
SYMPTOMS: (CHECK ALL THAT APPLY)
|
Depressed Mood |
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Decreased Energy |
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Delusions |
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Hopelessness |
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Guilt |
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Paranoia |
|
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Irritability |
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Medical Problems |
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Hyperactivity |
|
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Obsessions/Compulsions |
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Grief |
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Hallucinations |
|
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Panic Attacks |
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Anxiousness |
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Elevated Mood |
|
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Financial Problems |
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Eating Disorders |
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Sleep Problems |
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Problems With Friends |
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Legal Problems |
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Difficulty Concentrating |
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Problems At Work |
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Problems At School |
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Learning Problems |
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Problems With Activities of Daily Living |
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Problems Controlling Temper |
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Marital/Relationship Problems |
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Sexual Problems |
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Difficulty Thinking Clearly |
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Family Problems |
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Other: |
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FAMILY HISTORY:
DESCRIBE ANY MEDICAL OR PSYCHIATRIC CONDITIONS OF YOUR PARENTS OR SIBLINGS:
PSYCHIATRIC
HISTORY:
(include all current/ prior inpatient
and outpatient treatment including dates, where you were in treatment, name of therapist
or doctor, names of all medication(s):
MEDICAL
HISTORY:
(include current and previous medical problems, all medications you are taking
including dosage, and any over the counter medication you are currently
taking).
ALLERGIES: YES____ NO___ (If yes, please
list)__________________________________________________________
HAVE YOU EVER
HAD AN ADVERSE REACTIONS /SIDE EFFECTS TO ANY MEDICATION(S): YES___ NO___
(If yes, please
list)_________________________________________________________________________________________
SUBSTANCE
ABUSE: HAS THE PATIENT EVER ABUSED DRUGS
OR ALCOHOL? YES___ NO___
If yes complete the following:
Previous
treatment: Outpatient: Where and
When_________________________________________________________
Inpatient: Where and
When_________________________________________________________
Cigarette use: YES___ NO___
Number per day: _______ Caffeine use: YES ___
NO ___ Amount________________
Revised 4/14/03 Form 2