Psychological Assessment Form Psychological Assessment Form Unique Code * The code provided to you by your health officer How old are you? * Gender * Marital status * Height (Feets) Weight (Kg) Symptoms Checklist (Please check all that applies to you) * Depressed mood Excessive worry Impulsivity Sleep pattern disturbance Loss of interest Decreased libido Concentration problems/forgetfulness Change in appetite Excessive guilt Decreased need for sleep Crying spells Increase risky behaviour Hallucinations Unable to enjoy activities Anxiety/ panic attacks Avoidance Increased libido Racing Thoughts Suspiciousness Excessive energy Increased irritability Excessive need for sleep Fatigue Lack of motivation None Have you been managed/ struggled with any of these in the past (check all that applies) * Anger Management Post Traumatic Stress Disorder Depression Anxiety Alcohol Abuse Other Substance Abuse (e.g. Marijuana, Tobacco) Schizophrenia Bipolar Affective Disorder Suicide/ Suicidal Thoughts ADHD Any other mental health need not listed above None of the above I have experienced some sort of trauma over the last six months * YesNoNot sure How would you classify your eating habit? * PoorExcellentGood How would you classify your sleep? * ExcellentGoodPoor Over the last one month, have you ever had feelings or thoughts that you didn’t want to live? * No Maybe Yes Do you currently feel hopeless and/or worthless? * Yes No Maybe Have you ever tried to kill or harm yourself in the past? * Yes No Maybe Have you ever had the thought to kill or harm someone else? * Yes No Maybe Do you have any allergies: (if none, write none. If yes, do write the allergy) * Current medical challenges (if none, write none) * Past medical challenges, nonpsychiatric hospitalization, or surgeries (if none, write none) * Do you have any concerns about your physical health that you would like to discuss with us? (if none, write none) * Have you ever had an outpatient treatment? * No Yes If yes, please provide details Have you ever had a psychiatric hospitalization? * Yes No If yes, please provide details Past/ Present Psychiatric Medications (check all that applies) Antidepressants Antipsychotics ADHD medications Mood Stabilizers Sedative/Hypnotics Antianxiety medications Others not listed here Do you exercise regularly? * Yes No How many days a week do you exercise? Have you ever been treated for alcohol, drug use? * Yes No If yes, for which substances? Check if you have ever tried any the following (check all that applies) * LSD or Hallucinogens Alcohol Tranquilizer/sleeping pills Marijuana Tobacco (Cigarettes, pipes, cigar, or chewing) Cocaine Pain killers (not as prescribed) Methadone Methamphetamine Heroin Stimulants (pills) Ecstasy None How many caffeinated beverages do you drink a day? * Have people annoyed you by criticizing your drinking or drug use? Maybe Yes No Have you ever felt you ought to cut down on your drinking or drug use? Yes No Maybe Have you ever felt bad or guilty about your drinking or drug use? Maybe No Yes How would you rate your relationship with your father? * Excellent Poor Good How would you rate your relationship with your mother? * Excellent Good Poor How would you rate your relationship with your siblings? * Poor Excellent Good Check any of the following that applied during your childhood/adolescence * Unhappy Childhood Alcohol Abuse Adventurous Legal Challenges Strong Religious Convictions School Challenges Drug Abuse Happy Childhood Emotional/ Behavioral Challenges Family Challenges Medical Challenges SECTION 9: TRAUMA HISTORY Do you have ANY traumatic experiences? * No Yes Maybe If yes, please provide details (please include details if there are multiple traumatic experiences) How would you grade your overall performance in secondary and primary school? * Above Average Below Average Average Were you bullied at any time in school? * Yes No Maybe If yes, please provide details of the bullying experience Did you bully anyone at any time in school? * Yes No Maybe If yes, please provide details of the bullying experience SECTION 13: LEGAL/ FINANCIAL Do you have any pending legal problems? * No Yes Do you have any pending debt problems? * No Yes Do you belong to a particular religion or spiritual group? * No Yes Do you find your involvement helpful, or does the involvement make things more difficult or stressful for you? * Helpful Very much helpful Unhelpful Very much unhelpful Is there anything else that you would like us to know? (if none, write none) * * I certify that the information provided on this form is true to the best of my knowledge * I acknowledge the use of the information provided on this form for the purpose of assessment and to provide help where needed * I acknowledge that I have read and understand the informed consent (request a copy from the health officer if you don’t already have one) Submit If you are human, leave this field blank. Δ
