Patient Information

This form provides Dr. Scheckner with pertinent patient background information. If you are the patient, please fill out with yourself in mind. If your child is the patient, please complete with the child in mind. Complete this form with as much detail as possible to appropriately treat your family.

Name Name First Last
Email
Social Security Number

(Do not include hyphens)
Age
Birthdate Birthdate / MM / DD YYYY
Lives with

Lives with Self Both parents Mother Father Other Other
Parents

Parents Married Separated/Divorced Widowed
Divorce
How old was patient when they divorced?
Emotions surrounding divorce
Custody arrangement
Feelings towards step-parents
School / Occupation
Current / Highest Grade Completed
Academic Difficulties
Physical (Health) Problems
Social Issues
Family Conflict
Parenting Style
Mental Health Issues (anxiety, depression, etc.)
Mother's Background
Name Name First Last
Occupation
Academic Difficulties
Physical (Health) Problems
Mental Health Issues
Fathers's Background
Name Name First Last
Occupation
Academic Difficulties
Physical (Health) Problems
Mental Health Issues
Step-Mother's Background
Name Name First Last
Occupation
Academic Difficulties
Physical (Health) Problems
Mental Health Issues
Step-Father's Background
Name Name First Last
Occupation
Academic Difficulties
Physical (Health) Problems
Mental Health Issues
Sibling(s)
Name Name First Last
Age
Academic Difficulties
Physical (Health) Problems
Mental Health Issues
Name Name First Last
Age
Academic Difficulties
Physical (Health) Problems
Mental Health Issues
Family History

Please describe if any of the following events have occurred in your family or to your child?
Select all applicable

Select all applicable Loss of job by parent Mother beginning to work Discovery of being adopted Death of parent Child changes schools Birth of brother or sister Marital separation/divorce Child is victim of violence Witnessed violence Family member in serious trouble with the law Child/parent acquires a visible deformity or diagnosed with severe illness Death of close family member/friend other than parent Addition of new adult to family Eating Disorder Drug Addiction Alcoholism Natural Disaster Physical Abuse Sexual Abuse Emotional Abuse Physical Neglect Emotional Neglect Other Trauma Other Trauma
Prenatal Development

Did patient's mother:
Take any medication during pregnancy?

Take any medication during pregnancy? No Yes (please describe) Yes (please describe)
Smoke during pregnancy?

Smoke during pregnancy? No Yes (please describe) Yes (please describe)
Drink alcohol during pregnancy?

Drink alcohol during pregnancy? No Yes (please describe) Yes (please describe)
Use illicit drugs during pregnancy?

Use illicit drugs during pregnancy? No Yes (please describe) Yes (please describe)
Have prenatal care?

Have prenatal care? No Yes (please describe) Yes (please describe)
Feel emotionally unprepared/unwanted pregnancy?

Feel emotionally unprepared/unwanted pregnancy? No Yes (please describe) Yes (please describe)
Birth History
Were there any problems during pregnancy?

Were there any problems during pregnancy? No Yes (please describe) Yes (please describe)
Were there any problems during labor or delivery?

Were there any problems during labor or delivery? No Yes (please describe) Yes (please describe)
Were there any birth defects or complications after delivery?

Were there any birth defects or complications after delivery? No Yes (please describe) Yes (please describe)
Infant Development

Were there any setbacks/problems in the following areas:
Physical Development

(abnormalities in growth)
Motor Development

(sitting, crawling, standing, walking, toilet
training)
Cognitive Development

(communication: speaking, reasoning,
comprehension)
Emotional Development

(expression, understanding)
Social Development

(parental attachment, peer/stranger interaction)
Child Development

Were there any setbacks/problems in the following areas:
Physical Development

(abnormalities in growth)
Motor Development

(fine motor and gross motor skills)
Cognitive Development

(communication: speaking, reasoning,
comprehension)
Emotional Development

(anger problems, sensitivity, moody, anxiety,
depression, low self-esteem)
Social Development

(parental attachment, peer/stranger interaction)
Medical History

Does the patient have/has had:
Select all applicable

Select all applicable Allergies Asthma Earaches or Infection Vomiting Spells Prolonged Fever Head Injury Seizures or Convulsions Operations or Surgeries Extended Hospitalizations Sustained Medications Physical Handicaps Wetting/Soiling Pants (after toilet training) Other Other
Eating/Sleep History

Describe if any of the following problems are occurring:
Select all applicable

Select all applicable Nightmares Trouble falling asleep Trouble waking up Constantly tired Wetting/Soiling Pants (after toilet training) Eats too much Poor appetite Grinds teeth Unhealthy eating Other Other
Presenting Issue(s)
Briefly describe your reason(s) for seeking help
How severe are the symptoms?

How severe are the symptoms? Mild Moderate Severe
How long has this occurred?
When does this occur?

(certain times of day, with specific people)
Where does this occur?

(home, school, community, etc.)
How have you attempted to resolve these concerns?
Has this been treated by other mental health professionals?

Has this been treated by other mental health professionals? No Yes
Is so, when and for how long?
How was your experience (good and bad) and why?
Is the patient taking any medications for this concern?

Is the patient taking any medications for this concern? Yes No
List medications and when taken.
What are current goals for counseling?
Has anyone in your family history ever been suicidal?

Has anyone in your family history ever been suicidal? No Yes
Have you been suicidal in the past?

Have you been suicidal in the past? No Yes
Are you currently suicidal?

Are you currently suicidal? No Yes
Referral Information
Who Referred You? Who Referred You? First Last
Their Phone Number Their Phone Number - ### - ### ####

Patient Information

Patient Information

Divorce

Mother's Background

Fathers's Background

Step-Mother's Background

Step-Father's Background

Sibling(s)

Family History

Prenatal Development

Birth History

Infant Development

Child Development

Medical History

Eating/Sleep History

Presenting Issue(s)

Referral Information