Adult History Form – Houston Neuropsychology Associates

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Houston Neuropsychology
Associates, PLLC

713-893-7105
Fax: 713-893-7145
office@houston-npa.com

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Houston Neuropsychology Associates, PLLC

Adult History Form

Please answer all of the following questions to the best of your ability. When finished, click on the Submit button. The information will then be sent securely to our office. There is no need to print this form.

Please note that items with an asterisk (*) are required.

Demographics
This field is hidden when viewing the form
Source
Patient's Full Name*
First Middle Last
Person Completing Form*
Please indicate who is completing this form.
Form Completer's Name*
Please enter the name of the person completing this form.
First Middle Last
Form Completer's Relation to Patient*
Please indicate the relationship of the person completing this form to the patient.
Patient's Date of Birth*
MM slash DD slash YYYY
Date of Patient's Appointment*
MM slash DD slash YYYY
Patient's Gender*
Patient's Handedness*
Please select the hand most often used for writing and other tasks.
Patient's Ethnicity*
Patient's Marital Status*
Patient's Employment Status*
Patient's Education Level*
Medical History
Medical Conditions*
Please check the box next to each condition for which a doctor has diagnosed or treated you, either now or in the past. Select the last option (none of the above) if you have none of these conditions.
- Hypertension (high blood pressure)
- Hyperlipidemia (high cholesterol)
- Diabetes
- Obesity
- Heart disease
- Cardiac arrhythmia
- Stroke
- Cancer
- Hypothyroidism (low thyroid)
- Hyperthyroidism (overactive thyroid)
- Kidney disease
- Chronic obstructive pulmonary disease
- HIV/AIDS
- Sleep apnea
- Cataracts
- Glaucoma
- Macular degeneration
- Hearing loss
- Parkinson's disease
- Multiple sclerosis
- Seizure disorder
- Serious head injury
- None of the above
Other Medical Condition(s)
If you have a medical condition not listed above, please enter it here.
Have you fallen in the past year?*
Do you feel unsteady when standing or walking?*
Do you ever use an assistive device, such as a cane, walker, or wheelchair?*
Nicotine Use*
Please consider cigarettes, cigars, pipes, and smokeless tobacco, as well as e-cigarettes.
Alcohol Use*
Please consider beer, liquor, and wine.
Substance Use*
Please consider any recreational drugs (e.g., cannabis).
Medications*
Please list all medications that you currently take. Enter NONE if you do not take any medications.
Surgeries*
Please list all surgeries that you have had. Enter NONE if you have not had any surgeries.
Family Medical History
Mother's Health*
Please list any medical or mental health problems your mother has (or had). If you were adopted, enter ADOPTED. If the information is unknown, enter UNKNOWN.
Father's Health*
Please list any medical or mental health problems your father has (or had). If you were adopted, enter ADOPTED. If the information is unknown, enter UNKNOWN.
Sibling Health
If you have any brothers or sisters, please list any medical or mental health problems that any of them have (or had). If the information is unknown, enter UNKNOWN.
Mental Health History
Psychiatric Medications*
Please indicate if you have ever taken medication for a mental health issue, such as depression or anxiety.
Psychological Therapy or Counseling*
Please indicate if you have ever participated in therapy or counseling for a mental health issue, such as depression or anxiety.
Alcohol Problems*
Please indicate if you have ever been diagnosed with or treated for alcohol problems.
Substance Abuse Problems*
Please indicate if you have ever been diagnosed or treated for substance abuse problems.
Psychiatric Hospitalization*
Please indicate if you have ever been hospitalized for a mental health issue.
Suicide*
Please indicate if you have ever attempted suicide.

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