Providing the below information prior to your appointment will help facilitate effective use of your appointment time with your Psychiatrist. Additional information like your sleep, appetite, eating, weight gain or loss, mood, self-harm/suicide thoughts, any experiences of hearing voices, seeing things that others cannot, memory, paranoia, anxiety, panic attacks, irritability, racing thoughts will be discussed in the room with your psychiatrist. We thank you in advance for your assistance.NameDOB DD slash MM slash YYYY AgeSexPlease list any symptoms that you are currently experiencing.Please list all health practitioners you have seen for your mental health including when you were a child.Have you ever been hospitalised for your mental health or presented to the Emergency Department? If yes please advise where, when and why?Have you ever had psychological therapy or psychotherapy? If yes, please advised who did you see, when, what modality for example CBT, DBT, CAT etc, how many sessions, what did it help with, how effective was it?Have you ever had ECT, TMS or other neurostimulation procedures? If yes please advise where, when, how many sessions, what did it help with, how effective was it?Please list past medications you have used for your mental health including dose and effect.Please list side-effects to all medications you have tried to date for your physical and mental health including name, dose, side effect and treatment.Please list all current medications you are taking including non-prescription/over the counter medications, vitamins and supplements.Any alcohol or other substances use now or in the past (including cannabis/marijuana, MDM, LSD or other hallucinogens, opiates, benzodiazepines, sedatives/hypnotics, cocaine, crack, methamphetamine, any other amphetamines, ritalin, heroin, street/illicit methadone, inhalants/other substances)SubstanceAge of 1st useHow much and how often ?How many years of use ?When last used ? Add RemovePast Medical History – Do you now or have you ever had – Please tick Y for Yes and N for No High Blood Pressure Yes No Diabetes Yes No High Cholesterol Yes No Hypothyroidism Yes No Hyperthyroidism Yes No Angina/Chest Pain Yes No Goitre Yes No Heart Problems Yes No Head Injuries Yes No Fractures Yes No Stomach or Peptic Ulcer Yes No Heart Murmur Yes No Asthma Yes No Pulmonary Embolism Yes No Emphysema Yes No Stroke Yes No Epilepsy/Seizures Yes No Cataracts Yes No Glaucoma Yes No Heartburn Yes No HIV/AIDS Yes No Psoriasis Yes No Syphilis Yes No Kidney Disease Yes No Crohn’s Disease Yes No Colitis Yes No Kidney Stones Yes No Anemia Yes No Hepatitis Yes No Rheumatic Fever Yes No Tuberculosis Yes No Jaundice Yes No Cancer Yes No Cancer (type and treatment)Known AllergiesPersonal History – Please eleborate where applicable Birth – Early/late/on time, natural/induced/C-section, any problems with your birth (please specify)?Any time spent in Paediatric ICU after birth?Where were you born and raised?Any delay in development milestones?Any assessments in school, any dyslexia, dyscalculia or other learning difficulties, any extra support at school, serious life events, any significant issues during schooling?Any prolonged periods of thumb sucking or bedwetting, temper tantrums, tics, head banging, night terrors, nail biting, stuttering, sleepwalking as a child?Any sensitivity to food texture or taste, smell, bright lights, nose or sounds, textures of clothing etc?Any assessments for ADHD or Autism/Asperger’s?Any contact with the school or guidance counsellors?Were you seen by any health professionals as a child?Any childhood trauma?Highest education?Religion, if any?Are you in a relationship – single, married, partnered/significate other, divorced, separated, widowed?Past and current occupation?Are you currently working – How many hours per week/sick leave/disabled/retired?Do you receive a disability support pension? It Yes, what disability and how long?Your relationship, any children?Family History – Living/deceased, any physical health conditions such as heart problems, high blood pressure, bleeding/clotting issues, diabetes, dementia, cancer. Any mental health conditions such as autism, asperger’s, ADHD, depression, anxiety, PTSD, psychosis, schizophrenia, mania, bipolar illness, personality disorder, suicide/self-harm, excessive alcohol/drug use, OCD. FatherMotherSiblingsOthersForensic/Legal History – Any Charges/convictions/speeding fines/Workcover or Insurance claims/other legal issues Sexual Health Age of first period - Do you have regular periods?PregnanciesMiscarriages / AbortionsHave you reached menopause? Is Yes, at what age?Any Sexual Health related issues
