Pre Initial Consultation Form
Thank you for your enquiry, please can you complete the following for us to schedule an initial consultation for you
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If Yes, please provide your name, address, phone number and relationship.
How did you hear about us?
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Patient Information
Full Name
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Mr.
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First Name
Last Name
Date of birth
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Day
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Month
Year
Date
What is your age?
Email
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Phone Number
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What is your ethnic origin?
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Weight in KG
Height in CM
What is your gender?
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Your address
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Occupation
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e.g. Retired, Student, Hairdresser, Unemployed, Administrator etc
NHS Number
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Insurance Provider
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None/Private
AVIVA
AXA PPP
BUPA
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Insurance Membership Number
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Authorisation code
Excess Amount
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Please select the clinic location which is closest to you
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Select your preference for attending the consultation
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In person at the clinic
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Contacts
Next of kin
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Name of your GP
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GP Email address
Surgery address
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Street Address
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Do you give consent for us to write to your GP for reasons such as medication recommendations?
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Do you give consent for us to speak to your family for reasons such as treatment plans, welfare checks and/or other clinic-related matters?
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Signature (Patient signature)
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Patient signature required solely for consent to contact and communicate with GP and/or family.
Do you consent to receiving emails and/or calls for welfare checks, treatment plan discussions, or other clinic-related matters?
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Are you registered with a psychiatrist?
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When did you last see your psychiatrist?
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Please provide the name, address and any contact details of your psychiatrist
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Do you give consent for us to contact your psychiatrist if we have recommendations or need further information?
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Further Details
Brief outline of your concerns
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What is your diagnosis?
Please state
Do you have or have you had Epilepsy/Seizures/Blood clots?
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Epilepsy
Seizures
Blood clots
None of the above
Do you have presence of any metal in the brain or scalp?
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Presence of metal in the brain or scalp
Cochlear implant
Metal rings
Hearing aids
None of the above
Are you currently taking any medication?
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Please list them.
Do you have any medication allergies?
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If yes please specify:
Do you use any kind of illegal drugs or have you ever used them?
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What kind of drugs? How long have you used/been using them?
Do you smoke?
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How often do you consume alcohol?
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Occasionally
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How many units of alcohol do you drink on a typical day when you are drinking?
1-2
3-4
5-6
7-9
10+
Enter your preferred date and time of day for your initial consultation appointment please note this is not a confirmed date.
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PATIENT HEALTH QUESTIONNAIRE-9
PHQ 9 /27
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things
*
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless
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Not at all
Several days
More than half the days
Nearly every day
Trouble falling or staying asleep, or sleeping too much
*
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy
*
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating
*
Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
*
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television
*
Not at all
Several days
More than half the days
Nearly every day
Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot, more than usual
*
Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way
*
Not at all
Several days
More than half the days
Nearly every day
PHQ-9 Total
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Hospital Anxiety and Depression Scale
Do not take too long over your replies: your immediate reaction to each item will probably be more accurate than a long thought-out response.
Anxiety
/20
I feel tense and 'wound up'
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Most of the time
A lot of the time
Time to time, occasionally
Not at all
I get a sort of a frightened feeling like something awful is about to happen
*
Very definitely and quite badly
Yes, but not too badly
A little, but it doesn't worry me
Not at all
Worrying thoughts go through my mind
*
A great deal of the time
A lot of the time
From time to time, but not too often
Only occasionally
I can sit at ease and feel relaxed
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Definitely
Usually
Not often
Not at all
I get sudden feelings of panic
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Very often indeed
Quite often
Not very often
Not at all
I feel restless as if I have to be on the move
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Very much indeed
Quite a lot
Not very much
Not at all
I get a sort of frightened feeling like 'butterflies in the stomach'
*
Not at all
Occasionally
Quite often
Very often
HADS-A Total
Depression
/21
I still enjoy the things I used to enjoy
*
Definitely as much
Not quite so much
Only a little
Not at all
I can laugh and see the funny side of things
*
As much as I always could
Not quite so much now
Definitely not so much now
Not at all
I feel as if I am slowed down
*
Nearly all of the time
Very often
Sometimes
Not at all
I have lost interest in my appearance
*
Definitely
I don't take as much care as i should
I may not take quite as much care
I just take as much care as ever
I feel cheerful
*
Not at all
Not often
Sometimes
Most of the time
I look forward with enjoyment to things
*
A much as I ever did
Rather less than I used to
Definitely less than I used to
Hardly at all
I can enjoy a good book or radio or TV programme
*
Often
Sometimes
Not often
Very seldom
HADS-D Total
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General Anxiety Disorder
GAD-7 /21
Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious, or on edge
*
Not at all sure
Several days
Over half the days
Nearly every day
Not being able to stop or control worrying
*
Not at all sure
Several days
Over half the days
Nearly every day
Worrying too much about different things
*
Not at all sure
Several days
Over half the days
Nearly every day
Trouble relaxing
*
Not at all sure
Several days
Over half the days
Nearly every day
Being so restless that is hard to sit still
*
Not at all sure
Several days
Over half the days
Nearly every day
Becoming easily annoyed or irritable
*
Not at all sure
Several days
Over half the days
Nearly every day
Feeling afraid as if something awful might happen
*
Not at all sure
Several days
Over half the days
Nearly every day
GAD-7 Total
Hamilton Depression Rating Scale (HAM-D)
Obsessions are unwanted ideas, images or impulses that intrude on thinking against your wishes and efforts to resist them. They usually involve themes of harm, risk and danger. Common obsessions are excessive fears of contamination; recurring doubts about danger, extreme concern with order, symmetry, or exactness; fear of losing important things.
1. Depressed mood (Gloomy attitude, pessimism about the future, feeling of sadness, tendency to weep)
*
Absent
Sadness, etc
Occasional weeping
Frequent weeping
Extreme symptoms
2. Feelings of guilt
*
Absent
Self-reproach, feels he/she has let people down
Ideas of guilt
Present illness is a punishment; delusions of guilt
Hallucinations of guilt
3. Suicide
*
Absent
Feels life is not worth living
Wishes he/she were dead
Suicidal ideas or gestures
Attempts at suicide
4. Insomnia - Initial (difficulty in falling asleep)
*
Absent
Occasional
Frequent
5. Insomnia - Middle (Complaints of being restless and disturbed during the night. Waking during the night)
*
Absent
Occasional
Frequent
6. Insomnia - Delayed (Waking in early hours of the morning and unable to fall asleep again)
*
Absent
Occasional
Frequent
7. Work and Interests
*
No difficulty
Feelings of incapacity, listlessness, indecision and vacillation
Loss of interest in hobbies, decreased social activities
Productivity decreased
Unable to work. Stopped working because of present illness only. (Absence from work after treatment or recovery may rate a lower score)
8. Retardation (Slowness of thought, speech, and activity; apathy; stupor)
*
Absent
Slight retardation at interview
Obvious retardation at interview
Interview difficult
Complete stupor
9. Agitation (Restless associated with anxiety)
*
Absent
Occasional
Frequent
10. Anxiety - Psychic
*
No difficulty
Tension and irritability
Worrying about minor matters
Apprehensive attitude
Fears
11. Anxiety - Somatic (Gastrointestinal, indigestion, cardiovascular, palpitation. headaches, respiratory, genito-urinary, etc)
*
Absent
Mild
Moderate
Severe
Incapacitating
12. Somatic symptoms - Gastrointestinal (Loss of appetite, heavy feeling in abdomen; constipation)
*
Absent
Mild
Severe
13. Somatic symptoms - General (Heaviness in limbs, back or head; diffuse backache; loss of energy and fatiguability)
*
Absent
Mild
Severe
14. Genital Symptoms (Loss of libido, menstrual disturbances)
*
Absent
Mild
Severe
15. Hypochondriasis
*
Not present
Self-absorption (bodily)
Preoccupation with health
Querulous attitude
Hypochondriacal delusions
16. Weight loss
*
No weight loss
Slight
Obvious or severe
17. Insight (Insight must be interpreted in terms of patient's understanding and background)
*
No loss
Partial or doubtful loss
Loss of insight
HAM-D Total
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