ADULT PRE- ASSESSMENT FORM
Please complete this form to the best of your ability so that we may provide the best possible service for you. If you have any recent reports completed by other health professionals (psychologist, neurologist, ENT, etc.), kindly bring copies of these with you at your first appointment or you may fax/email them in advance. Please note that all information given is kept strictly confidential and will only be released with your written consent. We look forward to meeting you!
NAME
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ADDRESS
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DATE OF BIRTH
MM
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DD
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YYYY
MOBILE NUMBER
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EMERGENCY CONTACT PERSON & PHONE NO
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RELATIONSHIP WITH EMERGENCY CONTACT PERSON
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HOME NUMBER
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EMAIL ADDRESS
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OCCUPATION
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MARITIAL STATUS
REFERRED BY
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MAY WE CONTACT THE REFERRER FOR ADDITIONAL INFORMATION OR CLARIFICATION?
IF YES, PLEASE PROVIDE A SPECIFIC NAME, ORGANISATION IF APPROPRIATE & CONTACT INFORMATION
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WHAT LANGUAGES DO YOU SPEAK?
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IF MORE THAN ONE LANGUAGE, WHICH IS YOUR PRIMARY LANGUAGE?
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DESCRIBE YOUR PROBLEM
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WHEN DID YOU FIRST NOTICE YOUR PROBLEM
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CAN YOU THINK OF ANY REASON OR CAUSE FOR YOUR PROBLEM ?
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HAS ANYONE ELSE IN YOUR FAMILY HAD A SIMILAR PROBLEM ?
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DOES THE PROBLEM INTERFERE WITH YOUR SOCIAL LIFE AND/OR EMPLOYMENT.
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DESCRIBE ANY MAJOR SURGERIES, MAJOR ACCIDENTS OR HOSPITALIZATIONS.
Please provide approximate dates and details.
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DO YOU TAKE MEDICATION (DRUGS) REGULARLY?
If yes, please provide name/type and reason for taking.
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DESCRIBE YOUR GENERAL HEALTH.
List any medical diagnoses/illnesses.
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LIST PREVIOUS EVALUATIONS AND/OR TREATMENTS RELATED TO YOUR CURRENT PROBLEM.
E.g. when, where, by whom, results
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PLEASE GIVE ANY OTHER INFORMATION YOU FEEL WILL BE HELPFUL
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