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	Decreased Energy	Delusions
Hopelessness	Guilt	Paranoia
Irritability	Medical Problems	Hyperactivity
Obsessions/Compulsions	Grief	Hallucinations
Panic Attacks	Anxiousness	Elevated Mood
Financial Problems	Eating Disorders	Sleep Problems
Problems With Friends	Legal Problems	Difficulty Concentrating
Problems At Work	Problems At School	Learning Problems
Problems With Activities of Daily Living	Problems Controlling Temper	Marital/Relationship Problems
Sexual Problems	Difficulty Thinking Clearly	Family Problems
Other:

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:

Substance Amount Frequency First Use Last Use

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