Dr Amit Dahiya Intake Form

Psychiatric Initial Self Report

Prior to your initial appointment with Dr Amit Dahiya
Details can be approximate, please fill as much as you can. Please submit this form at least 1 week before your appointment. To secure your appointment, you will need to fill in the pre-payment registration form (due to the high levels of demand this is a requirement to secure your appointment date and time). The link to the payment registration form is at the end of this intake form.
Date*

DayMonthYear
Title
Patient Name*

First NameLast Name
E-mail*
example@example.com
FemaleMaleNon BinaryOther
Birth Date*

DayMonthYear
Contact Telephone*
Address*

Street Address

Suburb

CityState

Post Code
Next of Kin - Full Name*
Name for someone to contact in emergency
Relationship to you*
eg, Mother, Parent, sibling, other
Next of Kin Contact Telephone Number*
GP Name*

First NameLast Name
GP Clinic
Please enter name of your referring GPs Clinic
Other clinicians/agencies involved in care:
Pharmacy
Please enter name of your pharmacy and location

Psychiatric History

Have you ever suffered from/been diagnosed with any of the following:

Indicate your history below

Rows	Details + When
ADHD
Autism
Learning Disability
Intellectual Disability
Conduct Disorder/Oppositional Defiance Disorder
Developmental Disorder of Speech/Language
Other developmental delay
Depression
Generalised Anxiety Disorder
Panic Disorder
Specific Phobias
OCD (Obsessive-Compulsive Disorder)
PTSD (Posttraumatic Stress Disorder)
Bipolar Disorder (Manic Depressive Illness)
Schizophrenia/other Psychosis
Drug Induced Psychosis
Eating Disoder (Anorexia/Bulimia Nervosa)
Personality Disorder (specify)
Substance Use Disorder (specify)
Adjustment Disorder
Sleep Disorder
Self Harm/Suicide Attempt
Neurological Disorder (Epilepsy, Head Injury etc)
Trauma
Abuse (physical/emotional/sexual)
Prolonged Stress
Unusually Flexible Joints
Tic/Tourette's Disorder
Other Diagnoses

YesNo

Please indicate

Rows	Month/Year	Length of Stay	Which Hospital	Diagnosis
Admission 1
Admission 2
Admission 3
Admission 4
Admission 5
Admission 6

Previous Outpatient Psychiatric Treatment (please fill in all that apply)

Rows	Details + When (age/date)
Public Health Psychiatry Clinic
Private Psychiatrist
Psychologist (Talk Therapy)
GP for psychiatry treatment
NGO or other community agencies
NDIS support

Psychiatric Medications that have been trialled in the past.

Rows	Name	Dose	Duration
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10

Substance Use

Please mention amount used daily/weekly + age you started = when you last used

Rows	Current Use	Past Use
Alcohol
Nicotine
Caffeine
Cannabis
Methamphetamine
Heroin
Cocaine
Unprescribed Dexamphetamine
Unprescribed Opiates
Other Substances

YesNo
Please provide details (outpatient support/inpatient rehab etc)

Physical Health Issues

Please list any health issues and age when it occurred below

Rows	Type of physical health illness/injury	Age
•
•
•
•
•
•
•
•

Family History

of psychiatric problems

Please list any health issues and age when it occurred below

Rows	Relation	Name of Disorder
•
•
•
•

Life Chart

Developmental History

Please provide details regarding significant memories & experiences at following ages • Happy memories • Difficult Memories • Trauma • Mental Health Issues • Physical Health Issues • Educational Achievements/issues • Career start/end/issues • Relationship start/end/issues • Substance use • Legal Problems • Other events*

Rows	Experiences
0-5 years
6-10 years
11-15 years
16-20 years
21-30 years
31-40 years
41-50 years
50+

Required Medical Information
• If available, please bring/email the latest set of investigations/measurements that were done by your GP or other clinicans. You can ask your GP/clinician practice to send them directly to results@cygnetclinic.com.au or HealthLink ID: cygnetcl

• Any other relevant investigations/notes/rports from your past are also appreciated

• Please bring list of current medications and doses

Service Agreement & Conditions

Cancellation Fee

Please inform the referred Patient of Fees, incuding a DNA. Fees are available on cygnetclinic.com.au/psychiatricfees

Emergency

Please inform the patient that we are not an emergency service and not open after hours If in need of counseling after hours, please contact LifeLine on 13 14 33 or an Ambulance by dialing 000.

Review Process

Ensure that the patient knows that demand for Psychiatry is overwhelming and that each referral needs to be reviewed by the Psychiatrist before being accepted and booked in.
Thank you - Please Tap Submit Below

This will save your details securely, and direct you to the pre-registration form to secure your appointment time/date.
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Psychiatric Initial Self Report

Social Situation

Presenting Problems

Current Medications

Psychiatric History

Substance Use

Physical Health Issues

Family History

Life Chart

Required Medical Information

Additional Information

Thank you - Please Tap Submit Below

Rows	Allergic substance	Reactions
1
2
3
4
5
6