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Pre-assessment questionnaire
Hi and welcome to your healing journey!
I'm so glad to be your guide.
Please complete this form before we meet so that we have all the information at hand for your appointment and can best use the time we have together.
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Email
*
Your email
Date
MM
/
DD
/
YYYY
Name
*
Your answer
Surname
*
Your answer
ID number
*
Your answer
Home address
Your answer
Cell no
*
Your answer
Medical aid
*
Your answer
Medical aid no
*
Your answer
Medical plan
Your answer
I consent to paying any shortfall owing if the medical aid does not cover the full first consult fee or if paying privately that payment will be made within 24 hours after each session ?
*
Yes
No
Other:
Required
Emergency Contact Name
*
Your answer
Emergency Contact Number
*
Your answer
Emergency Contact Email address
Your answer
Referred by
Health care professional
Self
Other:
Clear selection
Date of birth
MM
/
DD
/
YYYY
Age
Your answer
Marital Status
Married
Single
Divorced
Widower
In a relationship
Do you have children
Yes
No
If you do have children what are their ages
Your answer
Current Employment
Your answer
Highest level of education
Your answer
Religion
Your answer
Right or left handed
Right
Left
Both
Clear selection
What is the reason for your visit ?
Your answer
Previous Psychiatric History
Have you ever seen a psychiatrist or psychologist in the past ?
Yes
No
Clear selection
If Yes :
Date / Name of Health Care Provider (HCP) / Type of HCP / Reason / Diagnosis / Treatment
Your answer
If Yes :
Date / Name of Health Care Provider (HCP) / Type of HCP / Reason / Diagnosis / Treatment
Your answer
If Yes :
Date / Name of Health Care Provider (HCP) / Type of HCP / Reason / Diagnosis / Treatment
Your answer
Have you had any previous hospital admissions for mental illness ?
Yes
No
Clear selection
If Yes :
Facility name / date of admission / reason for admission / outcome
Your answer
If Yes :
Facility name / date of admission / reason for admission / outcome
Your answer
Family History
Does anyone in your family have :
Depression
Anxiety
Bipolar mood disorder
Epilepsy
Dementia
Alcohol or drug abuse problem
Other:
If any options chosen for previous question, please give details on their current medication ?
Your answer
Are you on any medications currently
Yes
No
Clear selection
If yes, please include vitamins, herbs and other nutritional supplements
Your answer
Do you have any of the following medical conditions ?
Diabetes
Epilepsy
Asthma
Hypertension
Thyroid
Other:
Have you had surgery in the past ?
Yes
No
Clear selection
if Yes, what procedure and year
Your answer
Do you have any allergies ?
Yes
No
Clear selection
Gynecological History (Woman only)
When was your last period ?
MM
/
DD
/
YYYY
What contraception are you on ?
Your answer
If menopausal are you on any medication?
Your answer
Lifestyle:
Cigarettes: Never used OR how many smoked per day
Your answer
Alcohol: Never used OR estimation of drinks per week
Your answer
Alcohol from age _____ to ______
Your answer
Use of other recreational drugs ?
Your answer
Have you been treated for drug or alcohol abuse ?
Yes
No
Clear selection
If Yes, list date / facility / reason / outcome
Your answer
If Yes, list date / facility / reason / outcome
Your answer
Exercise
How many times do you exercise per week ?
Your answer
Type of exercise ?
Your answer
What are your leisure activities / hobbies ?
Your answer
Diet
List any food sensitivities or intolerances:
Your answer
Are you on a special diet ? What foods do you avoid ? Why ?
Your answer
Personal History
Was your mum healthy during her pregnancy with you ?
Yes
No
Clear selection
Did she smoke or drink or take drugs ?
Yes
No
Clear selection
Were there any complications after delivery ?
Your answer
Who was your main caregiver when you grew up ?
Your answer
How soon did your mum return to work after you were born ?
Your answer
Did you have normal milestones for walking, talking etc.
Yes
No
Clear selection
At School
Did you fail any grades ?
Yes
No
Clear selection
Did you have learning difficulties ?
Yes
No
Clear selection
Adulthood
Home and family
Who do you live with ?
Your answer
Who would you go to for support ?
Your answer
How are your relationships with those who you live with ? Spouse / Children
Your answer
Work
What education have you completed ?
Your answer
What are your current studies ?
Your answer
What is your current or previous work ?
Your answer
Have there been times when you were unable to work for health reasons ?
Your answer
Challengers and stressors
What major life decisions or changes are you facing ?
Your answer
What are the more significant stressors in your life right now ?
Your answer
How are you coping with this stress ?
Your answer
What 3 items do you keep closest to you and what value do each represent?
Your answer
What are the top 3 ways you spend your time and what value do each represent?
Your answer
What are the top 3 consistent actions that energize you the most and what value to each represent?
At the end
Your answer
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