Pre Assessment

Please complete the following form, if you feel uncomfortable with any of the questions just leave them out

Any questions ring Helen anytime on 07590489933

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.

PERSONAL DETAILS:

Name(Required)

First Last

Date of Birth

Phone number(Required)

please give your mobile number

Email(Required)

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

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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?

Have you ever seen a mental health practitioner and if so when and what for?

You may select more than one

Not seen any

Counsellor

Psychotherapist

Psychiatrist

CBT

Hypnotherapist

Life coach

NLP

Other please enter in box below

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

Social History

Did you/do you smoke?

Yes

Do you drink Alcohol?

Yes

Have you ever thought you should cut down on the amount of alcohol you drink?

Yes

Do you ever use alcohol to deal with your problem in any way?

Yes

Have you ever used illicit drugs?

Yes

Do you use illicit drugs?

Yes

Do you ever use illicit drugs to deal with your problem in any way?

Yes

How well do you sleep?

Sexual Orientation

Heterosexual

Gay

Bisexual

Other

Religion (past and present, if any)

PRESENT CONDITION

Please list your MAIN 2 symptoms/problems:

Main symptom/problem 1

Symptom 1: On a scale from 0 (no symptom) to 10 (unbearable), how you would rate the level of intensity of your symptom, at its WORST

Symptom 1: On a scale from 0 (no symptom) to 10 (unbearable), how you would rate the level of intensity of your symptom, at its BEST

Main symptom/problem 2

Symptom 2: On a scale from 0 (no symptom) to 10 (unbearable), how you would rate the level of intensity of your symptom, at its WORST

Symptom 2: On a scale from 0 (no symptom) to 10 (unbearable), how you would rate the level of intensity of your symptom, at its BEST

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?

Symptom 2: Is there a particular time of day or night when it is usually at it’s worst?

FAMILY HISTORY

Your Mother

How would you describe your Mother’s personality?

Select all that are appropriate

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?

Your Father

How would you describe your Father's personality?

Select all that are appropriate

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?

Other Family

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?

On a scale from 0 - 10, on average how much stress do you now believe you were you under as a Child

On a scale from 0 - 10, on average how much stress do you now believe you were you under as a Teenager

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?

Select family members that either have or had any disorders or illnesses

Father

Mother

Sisters

Brothers

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

Please select any of the following that you feel relate to you

Select all that are appropriate

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

Do you find it difficult to express vocally how you feel?

Yes

How do you deal with stress?

e.g. behaviour, symptoms etc

Below is a list of symptoms that are often stress-induced. Please select any of the conditions/symptoms that you have experienced in your life and then use the list to help you complete the History of Stressors section