Adult Health History

Today's Date*

Contact Information

Patient's Name*

Prefix First Middle Last Suffix

Date of Birth*

Gender & Orientation*

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 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*

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?

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?

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.

J. Gregory Turnbull, Psy.D., J.D.

Psychologist in private practice in Kailua, Hawaii

Initial Client information Form

Contact Information

Referral

Payment Information

Demographics and History

Family of Origin

Military History

Current Situation

Legal History

Maps & Other Resources

Let’s Talk