Adult History Form

Adult history form

  • ADULT HISTORY FORM(All information on this form is strictly confidential) Please complete all information on this form and submit online or bring it to the first visit. Thank you!
  • Suicide Risk Assessment
  • If YES, please answer the following
  • Medical History:
  • List ALL current prescription medications and how often you take them, including vitamins and supplements:
  • For women only:
  • Personal and Family Medical History:
  • Past Psychiatric History:
  • Exercise:
  • Family Psychiatric History: Has anyone in your family been diagnosed with or treated for:
  • Substance Use:
  • How many caffeinated beverages do you drink a day?
  • Family Background and Childhood History:
  • Trauma History:
  • Educational History:
  • Occupational History:
  • Relationship History and Current Family:
  • Legal:
  • Spiritual life:
  • Thank you for taking the time to complete this form so that LBP can best assist you.