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 ( ................
................

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