Comprehensive Neurodevelopmental History and Interview
---ADULT CNHI---
Bluestem Center for Child and Family Development
“Compassionate, Family-Centered Care”
Comprehensive Neurodevelopmental History and Interview Form
CNHI Version 11-2018 Domains Model © Bluestem Center
The information you provide on these pages is a valuable part of your evaluation. This information will be saved in your medical record and protected under Privacy Acts.
Please fill out using pen. Thank you for your assistance.
Please bring this form and copies of any previous evaluation or treatment reports to your appointment!
Your Name Date
Current Address
City County State Zip __________
Home Phone Cell Phone Work Phone
(Please circle your preferred phone)
Date of Birth Age
Sex: (you may leave blank) ( Female ( Male ( Other
Are you employed? ( FT ( PT ( Not at this time
Employer
What is your marital status?
( Single ( Married ( Divorced ( Widowed ( Separated ( Partnered
Spouse or Partner’s Name: ________________________________________________________
Emergency Contact, Name and Number:______________________________________________
Relationship to you:________________________________________________________
This evaluation is for (check all that apply):
( First-time evaluation ( Second opinion or consultation
( Updated evaluation for the purpose of: _________________________________________
( Transfer care from: ________________________________________________________
( Consider medication for: ____________________________________________________
( Psychological Testing for: ___________________________________________________
( Considering Therapy for: ____________________________________________________
Were you referred to Bluestem by another professional?
If yes, who? _____________________________________________________________________________
Should we send a summary of our evaluation to a health professional or other person? ( Yes ( No
If yes, please provide contact information:
Name________________________________________________________________________________
Address______________________________________________________________________________
Phone__________________________________Fax___________________________________________
Briefly, what are your main concerns at this time? _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
What are some of your strengths, positive points, skills, or interests: ______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Please let us know of cultural or ethnic values to be considered in our work with you:
______________________________________________________________________________________
Please list any social workers, therapists, or other professionals currently involved in your care:
1. Name__________________________________________________________________________
Address________________________________________________________________________
Phone__________________________________Fax_____________________________________
2. Name__________________________________________________________________________
Address________________________________________________________________________
Phone_________________________________ Fax_____________________________________
Evaluation and Treatment History
1. List any previous experiences with mental health care, including hospitalizations (if any), psychiatrists,
therapists, clinics, or other:
____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
____________________________________________________________________________________
2. What was most helpful? __________________________________________________________
_________________________________________________________________________________
Education and Employment History
1. Did you ever have special education services or extra tutoring while in school?
( Yes ( No If yes, please describe:
___________________________________________________________________________________
___________________________________________________________________________________
2. As a child, did you have discipline problems leading to suspensions or being expelled?
( Yes ( No If yes, please describe:
____________________________________________________________________________________
____________________________________________________________________________________
3. High School: ( Graduated from ___________________________ Class of: _____________
( GED ( Did not finish
4. College or post-high school training: _______________________________Years ________________
_______________________________________________________________________________
_______________________________________________________________________________
Degree and Year _________________________________________________________________
5. Additional job or career training or graduate school:
______________________________________________________________________________
Years Completed ___________ Degree or Certification ________________
6. Military Experience: ( Yes ( No
Branch: _________________ Years Served: ___________ Combat? (Yes ( No
7. Employment History:
Years Employer Position or Task
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Social History
1. Where do you live now?
( House in town ( Apartment ( House in the country ( Farm
( Mobile home ( Temporary housing ( Other:
2. Who else lives with you?
Name Relationship Age Occupation (if adult)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
3. Please list immediate family members (parents, children, siblings) not living with you:
Name Relationship Age Living where
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
4. Do you have any pets? ( Yes (No If yes, list:
5. Hobbies or interests (camping, science fiction, sports, hunting, reading, etc.):
________________________________________________________________________________
6. Do you attend a temple, church, or other house of worship?
( Occasionally ( Regularly ( No
Name and denomination
7. Check any of these life events you may have experienced:
( Parents divorced or separated ( Family move
( Family member seriously ill or injured ( Death in the family
( Harassment or conflicts outside the home ( Fights in the home
( Member of household moved in or out ( Changed jobs or lost a job
( Loss of an important friendship ( House fire or natural disaster damaging the home
( Serious accidental injury ( You or a family member were the victim of a crime
( Homelessness ( Marital or couple’s problems
Other: ___________________________________________________________________________
Did any of these events occur in the past 12 months? (Yes (No
If so, which ones?___________________________________________________________________
8. Does anyone in your household or family have special needs, health problems, disability, or an addiction?
If yes, please describe: ______________________________________________________________
_________________________________________________________________________________
9. Are you satisfied with your friendships? ( Yes ( No
10. How often do you spend time with friends?
_________________________________________________________________________________
11. Are you satisfied with your relationships with your family members or partner? ( Yes ( No
12. Do you have a supportive extended family (grandparents, aunts, uncles, cousins) who would help you if you asked? ( Yes ( No
13. Do you have concerns about getting along with people in your workplace? ( Yes ( No
15. How stressful is your current work environment? ______________________________________________
_________________________________________________________________________________________
Legal History
1. Do you have any current or pending legal concerns? ( Yes ( No
If yes, please describe: _______________________________________________________________________
_________________________________________________________________________________________
2. Have you ever been arrested? ( Yes ( No
If yes, please describe:
3. Have you ever been required to complete a class, go to jail, or serve time in prison? ( Yes ( No
If yes, please describe:
Financial
1. Do you have enough income to meet basic needs with some left over for fun? ( Yes ( No
2. Are you under stress from debt or other financial issues at this time? ( Yes ( No
3. Do you have problems with impulse buying, shopping, or gambling? ( Yes ( No
4. Will cost be a concern in treatment planning? ( Yes ( No
Family History: Please indicate whether any blood relatives have any of the following problems:
Brothers Biological Mother’s Biological Father’s Your
Self Sisters Mother Relatives Father Relatives Children
Hospitalized for mental or emotional problems ( ( ( ( ( ( (
Suicide or threatened suicide ( ( ( ( ( ( (
Victim of physical or sexual abuse ( ( ( ( ( ( (
Psychosis or schizophrenia ( ( ( ( ( ( (
Bipolar disorder or manic-depression ( ( ( ( ( ( (
PTSD ( ( ( ( ( ( (
Major Depression ( ( ( ( ( ( (
Anxieties, fears, phobias, panic attacks ( ( ( ( ( ( (
Obsessive-compulsive disorder or traits ( ( ( ( ( ( (
Problems with anger or aggression ( ( ( ( ( ( (
Legal problems, arrests, jail/prison time ( ( ( ( ( ( (
Alcohol or drug abuse ( ( ( ( ( ( (
Gambling, shopping or other compulsions ( ( ( ( ( ( (
Developmental delay or intellectual deficit ( ( ( ( ( ( (
Autism or Aspergers ( ( ( ( ( ( (
Attention deficits and/or hyperactivity ( ( ( ( ( ( (
Tics or Tourette’s Syndrome ( ( ( ( ( ( (
Learning disabilities, dyslexia ( ( ( ( ( ( (
Speech or communication problem ( ( ( ( ( ( (
Thyroid problems (over- or under-active) ( ( ( ( ( ( (
Heart disease ( ( ( ( ( ( (
Seizures or epilepsy ( ( ( ( ( ( (
Serious or chronic medical problems: ( ( ( ( ( ( (
Adult Health History
Date of most recent physical exam:_____________________________________________________________
Physician or Clinic:__________________________________________________________________________
Chronic (ongoing) medical problems/illnesses (Examples: high blood pressure, asthma…):
__________________________________________________________________________________________
__________________________________________________________________________________________
Serious childhood illnesses: ___________________________________________________________________
Are your immunizations up to date? ( Yes ( No ( Unsure
Please list any surgery or operations you’ve had:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Injuries (requiring medical care): _______________________________________________________________
Hospitalizations (for any reason): ______________________________________________________________
Sleep Patterns:
( Difficulty falling asleep ( Early or frequent waking at night
( Hard to get up and going in the A.M. ( Sleep paralysis
( Nap four or more times/week ( Snoring
( Sleepy or Fall asleep during the day ( Sleep-walking
( Nightmares ( Night sweats
( Regularly use sleep medicines ( Leg or foot cramps/leg jerking
Usual time you go to bed: __________Lights-out time: _________ Est. Time you fall asleep: _________
Awake time: ________ Time you get out of bed for the day: __________
Do you use CPAP or other aids to sleep: ( Yes ( No
Eating Patterns:
Have you been gaining or losing weight recently? On purpose? _______________________________
__________________________________________________________________________________
Please circle any dietary restrictions or choices that apply:
General diet Food allergies Gluten-free Lactose-free Casein-free Diabetic
Organic Vegetarian Vegan Halal Kosher Low-salt
Other: ____________________________________________________________________________
Exercise Pattern:
( Athletic, regular sports training _______ times per week
( Cardio exercise and/or weight training _______ times per week
( Aerobic sports, bike, swim, or other activities _______ times per week
( Walk, low-impact exercise _______ times per week
( Fairly sedentary – no regular exercise routine
Substance Use:
Caffeine : ( Never ( ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- this first tape of a 2 part series will demonstrate humane
- care assessor s manual washington state
- interprofessional standardized patient exercise patient
- authorization for collection and release
- health tips weebly
- a statement of faith for the storms of life
- from the moment they came for him escape had been out of
- comprehensive neurodevelopmental history and interview
- washington d c
Related searches
- surgery history and physical
- surgery history and physical form
- surgical history and physical requirements
- cms history and physical surgery
- outpatient history and physical guidelines
- pre surgery history and physical
- pre surgical history and physical
- history and physical before surgery
- starbucks history and background
- surgery history and physical sample
- history and physical documentation guide
- preoperative history and physical require