J. Gregory Turnbull, Psy.D., J.D.
Psychologist in private practice in Kailua, Hawaii
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Adult Health History
Initial Client information Form
Reasons for referral and relevant history. (It's a lot of questions. Thank you for the time and effort.)
Today's Date
*
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Contact Information
Patient's Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
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First
Middle
Last
Suffix
Date of Birth
*
MM slash DD slash YYYY
Gender & Orientation
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Do you have a preferred gender pronoun?
Mobile Phone
OK to text?
Yes
No
Ask me if you have concerns about confidentiality of your text messages. There are secure options.
Work Phone
Assuming it's OK to call you there.
Home Phone
Assuming it's OK to call you there.
Email
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
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American Samoa
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Panama
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Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
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Åland Islands
Country
OK to send mail to this address?
Yes
It's OK to send mail to my street address.
Referral
Person completing form
First
Last
If you are completing this form for the patient, please give you name and relationship (next field)
Relationship to Patient
Who referred you to Dr. Turnbull? Or, where did you find his information?
Reason for seeing Dr. Turnbull?
*
Estimate the severity of the problem
Mild
Moderate
Severe
How many sessions or how long do you think you might need to successfully resolve this problem?
1 to 10 sessions
10 to 20 sessions
20 or more sessions
Ongoing therapy
What do you consider your main strengths?
*
Payment Information
Other than for QuestMedicaid patients, you will owe a copay and Hawaii General Excise Tax. The copay amount is set by your insurance company. Hawaii GET is 4.712%. There may be a small processing fee for using credit/debit payment accounts.
Will you want statements/receipts?
*
No
Yes
Hard (paper) copy required?
No
Yes
May I send you PDFs by email or text?
*
No
Yes
If. yes, please provide the email address or other contact method.
Demographics and History
Disability Status
E.g., VA rating, SSI, SSDI, other
Are you employed?
Employed
Unemployed
Retired
Disabled
What job do you have?
What and when was your last job?
Marital Status
*
Single
Partnered
Married
Separated
Divorced
Widowed
Never married
Education
Some high school
Graduated high school or GED
Some college
4-year college degree
Masters Degree
Doctoral Degree
Do you have (or have you had) any of these medical problems?
Heart Disease
Lung - COPD/asthma
Immune System
Cancer
Diabetes
Neurological Disordero
Liver Disease
Kidney Disease
Dry cougho
Shortness of breatho
Fever
Do you have any other medical problems?
Are you currently taking any medications?
(Please list names, dosages, and prescribing doctor.)
Who is your primary care doctor?
Do you have any specialist doctors?
Were you ever diagnosed with a psychological disorder?
No
Yes
Please describe.
Have you ever been in counseling before?
*
No
Yes
When was it?
Did it Help?
Have you ever seen a psychiatrist before?
*
No
Yes
A psychiatrist is a medical doctor who may prescribe medication for psychological disorders. Dr. Turnbull is a psychologist (does not prescribe), but he often collaborates with patient's psychiatrists.
When was it?
What was it for?
Have you ever been in a psychiatric hospital?
No
Yes
Please describe
Have any of your family members been diagnosed or treated for a psychiatric problem?
No
Yes
Please describe
Family of Origin
Where were you born and raised?
*
Who raised you?
*
Any Sisters or Brothers?
*
Yes
No
Please list brothers and sisters (with ages)
Were there any drug or alcohol problems in your childhood home?
No
Yes
Please describe
Was there violence in your childhood home?
No
Yes
Please describe
Was there any abuse towards you?
None
Physical
Sexual
Verbal
Emotional
Military History
Were you ever in the military?
No
Yes
When? MOS? Rank? Separation date?
Current Situation
Who do you live with now?
How stressful are your finances?
Legal History
Were you ever convicted of a crime? Have you ever been a plaintiff?
No
Yes
Please describe
(examples: victim of a crime, filed for bankruptcy, have sued or been sued, etc).
Are you part of a religious/spiritual group?
Comments
This field is for validation purposes and should be left unchanged.
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