Pre-Assessment & Medical History Form

Please complete ALL sections of this form - information provided will be treated sensitively and confidentially.
Full Name*
Date of Birth*

MonthDayYear
Date
Age*
Marital Status
Occupation*
Address*
Contact number*
Email*
example@example.com
Doctor's name & surgery address*
Do you have a medical condition or disability?*

YesNo
If yes, please specify
Please list any medication you are on:
Reasons for medication
Please provide details of any past psychological/medical problems:
Have you had therapy or counselling before?*

YesNo
If yes, please specify when and what type, if you know
Have you been treated for any of the following?

Heart ProblemsEpilepsyDiabetesDepression
Have you had hypnotherapy before?*

YesNo
If yes, what date/year did you do it?

MonthDayYear
Date
Reason you are coming to therapy:*
Have you made previous efforts to solve the problem*

YesNo
Are any of the following issues currently a problem for you? If so, please select all that are relevant.*

Anxiety / stress / pressure / worryConfidenceWeightAnxiety attacksAppetiteSmokingInsomnia/disturbed sleepDepression/hopelessnessGriefGuiltAfraid to go places you don't feel safeAlcoholPhobiaBusiness/workRelationshipsJealousyParanoiaSexualityConfusionSpiritualPersonality changesSexual problemsAngerHabits
How intense are the symptoms*

SlightlyMildlyModeratelyHighlyExtremely
How frequently do you experience the problem?*

Occasionally / randomlyMore than a few times per monthMore than a few times per weekDailySeveral times a day
Do you ever experience thoughts of harming yourself or ending your life?*

NeverOccasionally, but never would act on themFrequently, but never would act on themOccasionally and worry I might act on themFrequently and worry I might act on them
Do you have a history of suicide or mental illness in your family?*

YesNo
Mother

Present as a parentAbsent as a parentAliveDeceased
Father

Present as a parentAbsent as a parentAliveDeceased
Parents

Still togetherSeparated or divorced
Siblings

I am an only childI have a sister/sI have a brother/sI am the eldestI am the youngestI am somewhere in the middle
How does your problem affect your work /social / personal life?*
When experiencing the problem, what negative thoughts do you have about yourself, other people or the situation?*
When you experience the problem, what do you do or avoid doing?*
What do you believe are the causes of the problem; what made you vulnerable to the problem in the first instance?*
Signed*

Clear
Date*

MonthDayYear
Date
Should be Empty: