New Client History Form

Please answer the questions included on this form at least 48 hours before your initial appointment. This online form is secure and encrypted by Snap forms. It is stored securely according to Australian privacy legislation and all data is encrypted.

This information will only be accessible by your psychiatrist. Your psychiatrist will review all the answer you provide, and use your to answers to assist with the interview process during your initial appointment.

While we appreciate you answering all questions included on this form, you may leave sections blank if you would not like to answer.

Patient Details

First Name *

Last Name *

Age (in years)

Gender

Preferred Pronoun

Mobile Number:

Email Address

Employment

Occupation

Relationship status

Children

Name of GP (General Practitioner)

Name of GP clinic

List of other health care provider's name, speciality and medical centre. Please use a seperate line for each provider.

Past Medical History

Additional info

How long have you had your NEUROLOGICAL condition for?

What are your current symptoms from your NEUROLOGICAL condition?

How long have you had your HEART condition for?

What are your current symptoms from your HEART condition?

How long have you had your ENDOCRINE, KIDNEY or LIVER condition?

What are your current symptoms from your ENDOCRINE, KIDNEY or LIVER condition?

What are your current symptoms from your LUNG condition?

How long have you had your LUNG condition for?

Do you have a history of seizures, epilepsy or metal in the head or neck?

Do you have any other previous medical conditions not listed above? If so for how many years or months have you had this condition for?

Past Family History

Which family member had the MENTAL HEALTH condition?

Which family member had the NEUROLOGICAL condition?

Which family member had the HEART condition?

Which family member had the ENDOCRINE, KIDNEY or LIVER condition?

Which family member had the LUNG condition?

Has your family members had any other health condition?

Psychiatric Presenting Symptoms and History

Please describe the recent symptoms you have been experiencing? What has been happening recently, that has led you to see a psychiatrist's review? *

How long have you had your symptoms for? *

Days/Weeks/Months/Years *

Please confirm if you have had depression?

Approximately what year were you diagnosed with Depression?

Have you ever been hospitalised for Depression

Are you currently in a depression episode? ie. within the last few months

Please select your current symptoms of depression?

Please confirm if you have had Bipolar?

Approximately what year were you diagnosed with Bipolar?

Have you ever been hospitalised for Bipolar?

Are you currently in a manic or depressive episode? ie. within the last few months

Please select your current symptoms of mania?

NILpressured/increased amount of speechracing thoughtsvery little sleep for consecutive daysgrandiose beliefs uncharacteristic risky or impulsive behaviours eg. spending large amounts of money

Please confirm if you have had Generalised Anxiety Disorder?

Approximately what year were you diagnosed with Generalised Anxiety Disorder?

Are you currently experiencing generalised anxiety symptoms? ie. within the last few months

Please confirm if you have had OCD?

Approximately what year were you diagnosed with OCD?

Have you ever been hospitalised for OCD?

Are you currently experiencing OCD symptoms? ie. within the last few months

Please confirm if you have had Post Traumatic Stress Disorder?

Approximately what year were you diagnosed with Post Traumatic Stress Disorder?

Have you ever been hospitalised for Post Traumatic Stress Disorder?

Are you currently experiencing Post Traumatic Stress Disorder symptoms? ie. within the last few months

Please select your current symptoms of Post Traumatic Stress Disorder?

NILnightmares related to the original traumaflashbacks related to the original traumaavoidance of anything that could remind you of the original traumahypervigilance (jumpy and on edge)decreased emotional expression

Please confirm if you have had Schizophrenia?

Approximately what year were you diagnosed with Schizophrenia?

Have you ever been hospitalised for Schizophrenia?

Are you currently experiencing symptoms of Schizophrenia? ie. within the last few months

Please select your current symptoms of Schizophrenia?

NILvoices (auditory hallucinations)visual hallucinationstactile hallucinations

Please confirm if you have had Borderline Personality Disorder?

Approximately what year were you diagnosed with Borderline Personality Disorder?

Have you ever been hospitalised for Borderline Personality Disorder?

Please select your current symptoms of Borderline Personality Disorder?

NILemotional dysregulationinability to tolerate rejection in romantic and non romantic relationshipsa tendency towards conflict in romantic and non romantic relationshipschronic emptinessimpulsivityanger management/rage

PAST HOSPITILISATIONS: Have you had any hospitalisations for mental health reasons. If so, please provide furthe detail eg. reason for admission, voluntary status, length of admission

Psychological Treatments

Choose which of the following you have seen? *

psychologisttherapistcouncellornone

What type of psychological therapy have you tried?

Name of your most recent psychologist?

How long have you been seeing them for?

Neurostimulation

Have you ever tried TMS or ECT (Electroconvulsive Therapy)? *

yesno

Medication

Please list the name, dose and frequency of all the medications you are currently taking? *

Have you ever taken any psychiatric or mental health medication? *

Have you ever taken an Antidepressant before? *

Current Antidepressant

Current Antidepressant *

Current Dose:

Frequency

How long have you taken it for?

Previous Antidepressant 1

Previous Antidepressant 1 *

Maximum dose reached (if known)

Reason for stopping

How long was this medication taken for?

Previous Antidepressant 2

Previous Antidepressant 2 *

Maximum dose reached (if known)

Reason for stopping

How long was this medication taken for?

Other Antidepressants:

Please provide details if you selected "Other" in any of the above questions

Allergies

Do you have any allergies to medication?

Please list any medication allergies you have had. What what was the reaction? *

Alcohol

Do you drink alcohol? *

What type of alcohol do you generally drink?

How much do you drink on average during a session?

How often do you drink?

Recreational Drugs

Have you used any recreational drugs in the last 5 years? *

What type of recreational drugs have you used in the lat 5 years?

Cannabis/Marijuana Amphetamines Opiates/Fentanyl/Oxycodone/HeroinLSD/mushrooms/PCP

How often do you use drugs?

Smoking

Do you smoke cigarettes?

How many cigarettes do you smoke a day?

TMS

Please click here to read the consent form, if you have been referred for a suitability assessment for TMS (Transcranial Magnetic Stimulation). TMS is a drug-free, medicare subsidised and evidence-based treatment for Depression, OCD, PTSD and Chronic pain (including fibromyalgia). If you would like to learn more about this treatment, please visit our website our contact our friendly staff.

DASS 21 (Depression and Anxiety Severity Scale)

For Admin:

(D) Scoring Guide

(A) Scoring Guide

(S) Scoring Guide

For Patients:

Please read each statement and select which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:

0 Did not apply to me at all (Never)

1 Applied to me to some degree, or some of the time (Sometimes)

2 Applied to me to a considerable degree, or a good part of time (Often)

3 Applied to me very much, or most of the time (Almost Always)

I found it hard to wind down *

0123

I was aware of dryness of my mouth *

0123

I couldn’t seem to experience any positive feeling at all *

0123

I experienced breathing difficulty eg excessively rapid breathing, breathlessness in the absence of physical exertion *

0123

I found it difficult to work up the initiative to do things *

0123

I tended to over-react to situations *

0123

I experienced trembling eg in the hands *

0123

I felt that I was using a lot of nervous energy *

0123

I was worried about situations in which I might panic and make a fool of myself *

0123

I felt that I had nothing to look forward to *

0123

I found myself getting agitated *

0123

I found it difficult to relax *

0123

I felt down-hearted and blue *

0123

I was intolerant of anything that kept me from getting on with what I was doing *

0123

I felt I was close to panic *

0123

I was unable to become enthusiastic about anything *

0123

I felt I wasn’t worth much as a person *

0123

I felt that I was rather touchy *

0123

I was aware of the action of my heart in the absence of physical exertion eg sense of heart rate increase, heart missing a beat *

0123

I felt scared without any good reason *

0123

I felt that life was meaningless *

0123

Declaration

I declare that the above information is correct. I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the quality of health care and treatment given to me.

Full name: *

Please sign here: *

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Date:

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