CASE HISTORY FORM FOR ADULTS
Instructions: The purpose of this form is to obtain a comprehensive picture of your background. In
psychological evaluation and counseling/psychotherapy, records are necessary, since they permit a more
thorough dealing with one’s problems. By completing this form as fully and as accurately as you can. It will
also lessen the need for asking you routine questions. It is understandable that you might be concerned
about what happens to the information about you because much or all of this information is highly
personal. Case records are strictly confidential.
Date: _______________________________
Name of the Client: _____________________________________ Nickname: _______________
Height: ________________________________ Weight: ____________________________
HEALTH HISTORY:
Please list any medication you are currently taking, or have been taking during the past 6
months and why (including aspirin, birth control pills, herbal remedies, OTC meds: laxatives,
cold medicines, diet aids, vitamins or any medicines that were prescribed or taken over the
counter)
Name of Medicine Reason for Taking Medicine
Any significant illnesses/ Medical Hospitalization/Operation you had/have:
Illness/Operation Date/Age
1. _________________________________________
2. _________________________________________
3. _________________________________________
4.
5.
Have you sought or received any prior professional assistance for your problems?
If yes, please list them in chronological order:
Name of Mental Health Professional Dates Consulted Reason for Consultation
When was the last time you had a complete physical exam? What were the remarkable results?
Do you have any current concerns about your physical health? If yes, please specify
Past Head Trauma: Any Seizures? __________________________________________________________
Ever had an EEG (electroencephalogram)? _______________________________________________________
Loss/Weight Gain: _______________________________
How many meals do you normally eat each day? ____________________________________
How would you describe your eating habits?
Any problem chewing, swallowing, digesting, or eliminating?
__________________________________________
Do you exercise regularly? How/what kind of physical exercise do you
do?____________________________
Do you have any problems walking/getting around? __________________________________________
Do you have any current concerns about your physical health? If yes, please specify
Do you have any body pain? If yes, where? ___________________________________________
If you have pain, on a scale of 1 to 10 (10 being the worst), how would you describe the pain?
____________________________________________________________________________________________
Describe your sleeping habits.
EDUCATION:
List the schools attended:
Name of School Grades/Year Level Attended Years Attended Year/Degree Completed
Elementary
High School
College
Others
School Experiences
How would you assess your performance in school?
Did you have problems in school? Please explain the circumstances briefly. (e.g. grades,
suspension, expulsion, etc.)
What were your academic strengths and special abilities?
What were your academic weaknesses and other areas of improvement?
How would you describe your relationship with your teachers?
Did you get along with your classmates?
1) If yes, what activities did you do together?
2) If no, please list your reasons
Do you have friends from school you still see to this day?
If yes, please list their names, how often you see each other, and activities you do
together:
Name Frequency of Meeting Activities
If no, please list your reasons
EMPLOYMENT
List the jobs you have held and their dates:
Job Held Employer Dates
______
Have you had any problems at your previous work? Please specify
Present Work
What do you like about your present job?
What do you dislike about your present job?
Describe your relationship with your superiors.
Describe your relationship with your co-workers.
Are there aspects about your work that do not satisfy you? Please specify
If you are not working at present, how do you support yourself?
If you could do anything you want without concern for earning a living, what would that be?
FAMILY OF ORIGIN
Parents
Mother Father
Name
Address
Age
Religious Affiliation
Ed. Attainment
Occupation (state if retired)
Birthplace
Marital Status(e.g. married, separated
, widowed, etc.)
If mother is deceased, give her age at time of death Cause of death
If father is deceased, give his age at time of death Cause of death
Siblings
Name of Sibling Age Civil Status Educational Attainment
Occupation
List any other significant people who used to live in your household:
Name Age Relationship
Mother
How would you describe your relationship with your mother?
1) As a minor
2) At present
How did your mother discipline you?
As a child, for what offenses were you often disciplined?
Father
How would you describe your relationship with your father?
1) As a minor
2) At present
How did your father discipline you?
As a child, for what offenses were you often disciplined?
Siblings
How would you describe your relationship with your siblings?
To whom are you closest? Please explain
With whom do you have conflicts? Please explain
List any significant childhood memories
How would you describe your childhood and adolescence? (e.g., happy, conflicted, etc.)
Who is the most supportive in your life and in what way?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_________
FAMILY OF PROCREATION
Marital Status
( ) Single ( ) Engaged ( ) Married ( ) Separated
( ) Divorced/Annulled ( ) Remarried ( ) Living-in with someone
Married Life
Spouse If Remarried
Name
Age
Religious Affiliation
Ed. Attainment
Occupation
Length of Courtship
No. of Years Married
Activities Together
How would you describe your marriage at this time?
Are there things about your husband/wife that you like changed? If yes, what things would you
like changed?
If divorced, or separated, for what reasons:
List names of children and other information:
Name of Child Age School Educational Status Civil
Status
Do any of your children present a special problem? If yes, please specify
How would you describe yourself as a parent?
Describe the activities you do with your children and the frequency of these:
Activity How often
List the people who are currently living in your household and their relationship to you:
Name Relationship
SOCIAL/ RECREATIONAL HISTORY
Recreation
What do you do in your spare time?
What are your hobbies?
Do you belong to any social clubs/ professional organizations? If yes, please list.
Name of Organization Date of Participation Position
Closest Friends
Name of Friends Origin of Friendship Activity Frequency
(Where did you meet them?) (What do you do together?) (How often do you see them?)
How are you like when you are with your friends? Briefly describe yourself when you are with
them.
SEXUAL DEVELOPMENT
How did you first learn about sex?
What sexual concerns did you have when you were growing up?
How old were you when you had your first boyfriend/girlfriend? first sexual
relationship?
Are you sexually attracted to members of the: ( ) opposite sex ( ) same sex ( ) both
What sexual experiences have you had since you became an adult?
( ) Pre-marital sexual intercourse ( ) One-night stand with commercial sex
worker
( ) Marital sexual intercourse ( ) Homosexual experiences
( ) Extramarital affairs ( ) Casual sex without involving any payment
( ) Others, please specify
How many sexual partners have you had? Men Women
Encircle a number from the scale below that best describes your level of satisfaction with
regards to your sex life at present?
very dissatisfied moderately satisfied very
satisfied
1 2 3 4 5
PERSONAL CHARACTERISTICS
What do you like best about yourself?
What do you like least about yourself?
If there were anything you could change in your life, what would they be? Please explain.
What are your dreams and future plans?
RELIGIOUS AND MORAL DEVELOPMENT
Religion
Did your family practice a religion when you were growing up? If yes, what practices did you
perform and how often?
Do you practice a religion today? If yes, describe briefly.
Personal Beliefs
Do you believe in a God?
If yes, how would you describe your relationship with God?
If no, why do you say so?
Please check the three (3) things you hold most important in your life?
( ) Money and a comfortable life ( ) Spirituality and Salvation
( ) Happiness and self-fulfillment ( ) Good and meaningful relationships
( ) Competence in something ( ) Esteem of others
( ) Pursuit of knowledge ( ) Service to others
( ) Others, please specify
