» Pre Ass

N.B. This pre-assessment is designed to help you begin to make connections between what has happened in your life and your symptoms. Your completed forms will remain confidential between you and your practitioner. Completing it is voluntary, but will help in your assessment, diagnosis and any follow up advice provided.

Phone number(Required)

please give your mobile number

Email(Required)

Note: a copy of this completed form will be sent to this email

Your Occupation and briefly what it entails:

Hobbies and Sports and whether your symptoms have affected your ability to do them:

PAST MEDICAL HISTORY

Have you ever had any operations or been in hospital? Please list roughly when and why

What diagnoses have you been given re. your pain and any other health condition? Please include any test results.

What medications do you take presently?

Counsellor(Required)

When did you see your counsellor and what for? Just approximate dates and brief description will do

Psychotherapist(Required)

When did you see your psychotherapist and what for? Just approximate dates and brief description will do

Psychiatrist(Required)

When did you see your psychiatrist and what for? Just approximate dates and brief description will do

CBT(Required)

When did you see your CBT practitioner and what for? Just approximate dates and brief description will do

Hypnotherapist(Required)

When did you see your hypnotherapist and what for? Just approximate dates and brief description will do

Life coach(Required)

When did you see your life coach and what for? Just approximate dates and brief description will do

NLP(Required)

When did you see your NLP practitioner and what for? Just approximate dates and brief description will do

Other(Required)

What mental health practitioner did you see ? When did you see them and what for? Just approximate dates and brief description will do

How well do you sleep?

Religion (past and present, if any)

PRESENT CONDITION

Please list your MAIN 2 symptoms/problems:

Main symptom/problem 1

Main symptom/problem 2

List the specialists/therapists you have seen and any treatments you have had for these symptoms/conditions.

List any other symptoms that are currently bothering you.

Please answer the questions below for each of the main 2 problems/symptoms you are presenting with.

Symptom 1: When did this symptom begin?

Symptom 2: When did this symptom begin?

Symptom 1: Do you/did you link this to a particular physical cause?

Symptom 2: Do you/did you link this to a particular physical cause?

Symptom 1: What was happening in your life when it began?

Symptom 2: What was happening in your life when it began?

Symptom 1: Give a brief history of how it has been since the onset and whether you can link this with any particular stresses.

Symptom 2: Give a brief history of how it has been since the onset and whether you can link this with any particular stresses.

Symptom 1: Is there a particular time of day or night when it is usually at it’s worst?

Other: add anything else you think is relevant(Required)

How would you describe your relationship with her as a child and now?

Was your Mother loving and affectionate with you, or the opposite? Was her love conditional?

please describe

Did she have high expectations of you or was she critical?

Other: add anything else you think is relevant(Required)

How would you describe your relationship with him as a child and now?

Was your Father loving and affectionate with you, or the opposite? Was his love conditional?

please describe

Did he have high expectations of you or was he critical?

Do you have any step parents and if so when did they come into your life and what influence do you feel they had on you?

Do you have siblings and if so where do you come in the family? Briefly explain what sort of relationship you have/had with them.

Did you have a number of changes during your childhood – such as moving house/school/area, being adopted etc?

Are you currently in a stable relationship? In 3 words how would you describe this?

Do you have children and if so, how old are they?

Do you have any step-children or adopted children?

List disorders or illnesses that your Father has/had(Required)

List disorders or illnesses that your Mother has/had(Required)

List disorders or illnesses that your Sisters have/had(Required)

List disorders or illnesses that your Brothers have/had(Required)

List disorders or illnesses that your Children have/had(Required)

SELF-INDUCED PRESSURES

Other: Enter below any other self induced pressure you think may be relevant.(Required)

How do you deal with stress?

e.g. behaviour, symptoms etc