Medical History

Emergency Assistance

If this is an emergency, call:

Client Information

First name

Last name

Today's Date

Past Medical History

Please describe the main problem or symptoms you are experiencing:

Please describe your problems or symptoms from the beginning:

Describe how these symptoms make you feel:

Length of symptoms

Was there a specific event(s) that caused the symptoms to begin? If so, please list.

What makes you feel worse or better?

Past Medical History

Other conditions we should be aware of?

Have you had any allergy or sensitivity to medicines or other substances?

Yes No

Add new row

Previous Surgeries and dates

Any serious injuries or broken bones?

Yes No

Please list with dates.

Have you had any dental problems, currently or in the past?

Yes No

Please list with dates.

Last menstrual cycle?

Periods are...

regular irregular

# of pregnancies

# of miscarriages

Do you have any children?

Yes No

Add new row

Are you currently using contraceptives?

Yes No

Have you ever had a blood transfusion?

Yes No

Current Medication List

Add another medication

Personal History

Where were you born?

How would you describe your upbringing?

Race/Ethnicity

American Indian Asian African American Hispanic Caucasian Other

Educational Background - Please list any degrees you have achieved.

Please select one from each of the 3 columns below:

Religious Affiliation, if any

Military Background, if any

Marital Status

single

married

divorced

separated

widowed

partnered

Number of Marriages

Number of Children

Length of time cohabitating with partner

Current Residence

own house/condo

renting

retirement complex

Who lives with you? List all.

Are you currently or have you ever been involved in a lawsuit?

Yes No

Current Tobacco Use?

Yes No

In the past?

Yes No

Type/Daily amount?

How long?

Do you drink alcoholic beverages?

Yes No

Type of Alcohol?

Do you use illicit drugs?

Yes No

Type of Drugs?

Do you drink coffee/caffeine?

Yes No

Daily Amount?

Weekly Amount?

Have you heard or seen things that others have not/hallucinations/paranoia?

Yes No

Have you experienced homicidal ideation?

Yes No

Have you experienced suicidal ideation?

Yes No

Are you experiencing memory loss/problems?

Yes No

Are you experiencing language/speech problems?

Yes No

Do you have any explanation for your symptoms? If so, please explain.

Have you been diagnosed with a mental illness or sought psychiatric services in the past?

Yes No

Please explain.

Height?

Weight?

Family History

Please check any illnesses that your parents, grandparents, or siblings have had:

Mental Illness Alcohol Abuse Drugs/Substance Abuse Diabetes Nervous Disorder Cardiovascular Disease Cancer Other

Cancer type?

Please describe other:

Do you have specific goals for treatment? If so, please list.

How would you describe your mood? Recently and long term/overall?

Your information will be encrypted.

Medical History

Emergency Assistance

Client Information

Past Medical History

Past Medical History

Current Medication List

Personal History

Family History

Emergency Assistance

Dawn L. Shogren M.D., P.A.