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BMHC Intake Form
Please fill in before your first psychiatric consultation — only if you are on the waiting list or have a confirmed appointment with one of our psychiatrists.
Full Name
First Name
Last Name
Mobile Phone Number
-
Country Code
Phone Number
Emergency Contact
Provide Name, Phone Number and Relationship
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Belgian Social Security Number
Required for electronic medical record and prescriptions
E-mail
example@example.com
CURRENT COMPLAINTS
Purpose of current visit
Referred by:
Self-referred
Family Doctor
Psychologist
Medical Specialist
Other
Current Family Doctor
Current Psychologist
If applicable
Current Psychiatrist
If applicable
Current Medication
Provide dosage, time, starting date
Current Substance Use
When present, please specify quantity and duration of use
OPTIONAL - Please indicate if you've been experiencing the following symptoms recently
Based on M.I.N.I. Mini International Neuropsychiatric Interview 5.0.0
Have you been consistently depressed or down, most of the day, nearly every day, for the past two weeks ?
In the past two weeks, have you been less interested in most things or less able to enjoy the things you used to enjoy most of the time ?
Have you felt sad, low or depressed most of the time for the last two years ?
In the past month did you think that you would be better off dead or wish you were dead ?
Have you ever had a period of time when you were feeling "up" or "high" orso full of energy or full of yourself that you got into trouble, or that otherpeople thought you were not your usual self ?
Have you, on more than one occasion, had spells or attacks when you suddenly felt anxious, frightened, even insituations where most people would not feel that way ? Did the spells peak within 10 minutes ?
Do you feel anxious or particularly uneasy in places or situations from whichescape might be difficult, and where help might not be available in case of panic attack, like being in a crowd, standing in a line (queue), when you are alone, away from home or alone at home, or when crossing a bridge,traveling in a bus, train or car ?
In the past month, were you fearful or embarrassed being watched, being the focus of attention, or fearful of being humiliated ?
In the past month, have you been bothered by recurrent thoughts, impulses or images that were unwanted, distasteful, inappropriate, intrusive ordistressing ?
In the past month, did you do something repeatedly without being able to resist doing it, like washing or cleaning excessively, counting or checking things over and over, or repeating, collecting, arranging things, or othersuperstitious rituals ?
Have you ever experienced or witnessed or had to deal with an extremely traumatic event that included actual or threatened death or serious injury toyou or someone else ?
During the past month, have you re-experienced the event in a distressingway (i.e., dreams, intense recollections, flashbacks or physical reactions) ?
Have you ever believed that people were spying on you, or that someonewas plotting against you, or trying to hurt you ?
In the past three months, did you have eating binges or times when you ate a very large amount of food within a 2-hour period ?
Have you worried excessively or been anxious about several things of day today life, at work, at home, in your close circle over the past 6 months ?
HISTORY
Prior treatments with a psychiatrist or psychotherapist
Please provide in chronological order
Prior Psychiatric Hospitalisations
Prior Psychiatric Medications
Please specify treatment, dosage, duration and effects/side-effects
Medical history
Do you have any medication allergies or other allergies?
Yes
No
Not Sure
History of traumatic life-events
Yes
No
Not sure
Family History of Mental Health Symptoms
If applicable: please specify family member and treatment
Back
Next
Consultation with:
*
Dr. Thomas Van der Poorten
Dr. Lucas Vanderlinden
Dr. Kris Naudts, PhD
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