Please check any of the following stressors that presently affect, or recently affected    Financial problems Family relationship problems Legal    Child rearing problems Drug or alcohol problems Employment    School problems Peer relationship problems Marital Problems Please check any of the following medical conditions for which you were ever evaluated or     Seizures Heart Problems Weight Problems Head     Asthma Chronic Fatigue Chronic Headaches     Surgeries Stomach Problems Suicidal Thoughts Chronic Hearing Loss Please check any of the following medical conditions for which you show a family     Seizures Heart Problems Weight Problems Sudden     Asthma Chronic Fatigue Chronic Headaches     Obesity Diabetes Mellitus Suicidal Thoughts Heart Disease Please indicate which, if any, of the following symptoms you are exhibiting: ADHD Depression Anxiety Abuse Hyperactive Sad Excessive Worrying Physical Impulsive Sleep Problems Panic Attacks Emotional Under Achievement Negative Thinking Irrational Fear Domestic Violence Non-Compliant Poor Concentration Obsessions Rape Inattentive Hopeless/Worthless Social Isolation Sexual Poor Concentration Mood Swings Phobias Dissociative Disorganized Guilt Compulsive Self-Control Fatigue/Lethargy Shyness Relationship Anger Addictions Other Marital/ Significant Other Short-fused Alcohol Agitated Sexual Problems Temper Tantrums Drugs Mania Parenting Impulse Control Gambling Paranoia Difficulty With Friends Violent/Assaultive Relationships/Sex Delusions Work/School Problems Runaway Risk Eating Disorders Tics/Tourettes Personal Growth Fighting Cyber/Internet Cutting Behavior Grief/Loss Irritable Spending Appetite Changes Bullying/Teasing Oppositional Tobacco Nightmares Flashbacks
Please check any of the following stressors that presently affect, or recently affected  Financial problems  Family relationship problems  Legal  Child rearing problems  Drug or alcohol problems  Employment  School problems  Peer relationship problems  Marital Problems Please check any of the following medical conditions for which you were ever evaluated or  Seizures  Heart Problems  Weight Problems  Head  Asthma  Chronic Fatigue  Chronic Headaches   Surgeries  Stomach Problems  Suicidal Thoughts  Chronic Hearing Loss Please check any of the following medical conditions for which you show a family  Seizures  Heart Problems  Weight Problems  Sudden  Asthma  Chronic Fatigue  Chronic Headaches   Obesity  Diabetes Mellitus  Suicidal Thoughts  Heart Disease Please indicate which, if any, of the following symptoms you are exhibiting: ADHD Depression Anxiety Abuse Hyperactive Sad Excessive Worrying Physical Impulsive Sleep Problems Panic Attacks Emotional Under Achievement Negative Thinking Irrational Fear Domestic Violence Non-Compliant Poor Concentration Obsessions Rape Inattentive Hopeless/Worthless Social Isolation Sexual Poor Concentration Mood Swings Phobias Dissociative Disorganized Guilt Compulsive Self-Control Fatigue/Lethargy Shyness Relationship Anger Addictions Other Marital/ Significant Other Short-fused Alcohol Agitated Sexual Problems Temper Tantrums Drugs Mania Parenting Impulse Control Gambling Paranoia Difficulty With Friends Violent/Assaultive Relationships/Sex Delusions Work/School Problems Runaway Risk Eating Disorders Tics/Tourettes Personal Growth Fighting Cyber/Internet Cutting Behavior Grief/Loss Irritable Spending Appetite Changes Bullying/Teasing Oppositional Tobacco Nightmares Flashbacks
Adult%20Intake%20Forms.docx