Patient Pre-assessment Form

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Patient Pre-Assessment Form

Please complete the following form prior to your psychiatric assessment at Living Well Psychiatry.

Full Name

Age

Are you currently under TAC, WorkCover, DVA or Victims of Crime? If so, which and what is your claim number?

Who lives at home with you?

What is your relationship status? If you are in a relationship, can you describe your relationship with your partner?

Do you have any dependents?

No

Yes

If so, how many? What are their ages? What is your relationship like with your children?

Are you employed?

No

Yes

If so, what do you do? Is this FT, PT or casual?

Are you studying?

No

Yes

If so, what are you studying?

What is the highest level of education you have achieved?

How many full, half and step siblings do you have?

Can you describe your relationship with your parents and siblings?

What are your hobbies?

What do you do to manage stress?

Have you ever been in trouble with the police?

No

Yes

If so, for what reason?

Do you smoke?

No

Yes

If so, how many cigarettes do you smoke daily?

Do you drink alcohol?

No

Yes

If yes, can you describe your pattern of drinking?

Do you use any drugs?

No

Yes

If so, what drugs do you use and how often?

Please list all your medical issues/diagnoses below and any treatment you are receiving for these:

Do you suffer from heart disease?

Does anyone in your family suffer from any mental health issues?

No

Yes

If so, who and what do they suffer from?

Can you please list any psychiatric diagnoses you have been given in the past?

Can you please list any current medications (and doses) you have been prescribed for your psychological condition?

Can you please list any medications you have been prescribed for any psychological conditions in the past? Please state the response or adverse effects you had with each of these medications:

Are you seeing a psychologist at present?

No

Yes

If yes, can you please provide the name, contact number, fax and email of your psychologist?

Do you consent to us sending your report to the above listed psychologist?

Yes

No

Thank you!

You have successfully submitted your pre-assessment form.

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Contact Us

Phone:  (03) 7066 4636

Fax:  (03) 9960 6111

PO Box 5012 
Alphington VIC 3078

admin@livingwellpsychiatry.com.au

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