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Medicine Assessment Form -Form Fill

Q1

First Name

Name*
Q2

Last Name

Name*
Q3

Month

Birth Date*
Q4

Day

Birth Date*
Q5

Year

Birth Date*
Q6

Phone Number

Phone Number*
Q7

Email*
Q8

What are you coming to counselling/support group session for?
Q9

Type of Therapy/Counselling you have received in the past and for what reason?
Q10

What was your reason for stopping?
Q11

First Name

Are you currently under a Doctor's Care? If yes, please provide following information:
Q12

Last Name

Are you currently under a Doctor's Care? If yes, please provide following information:
Q13

Are You Taking Any Medication? If yes, what kind and reason?
Q14

Have you ever considered suicide? If yes, please briefly describe:
Q15

Have you ever been diagnosed by a psychologist or psychiatrist with a ‘mental illness’ or DSM disorder (such as major depression, borderline personality disorder etc)? If so, what was the diagnosis and when did it occur?
Q16

My biggest source(s) of stress/anxiety are:
Q17

I would rate my current stress/anxiety on a scale of 0-10 (10 being high)
Q18

I have experienced the following:
Q19

Which of these physical symptoms do you experience?
Q20

Which of these cognitive symptoms do you experience?
Q21

When you are stressed do you choose:
Q22

Do you take the edge off by:
Q23

Please provide any further details about your stress/anxiety and trauma history that you feel may be relevant.
Q24

How do you take care of yourself?
Q25

Who do you turn to for support?
Q26

Tell us about your strengths, hobbies, interests. What do you like to do for fun and relaxation?
Q27

I envision my relationship with Empower Health Mind-Body Team...
Q28

I also think you should know......about me, so I can receive the best care possible.
Q29

I would like you to call me to set up my first appointment
Q30

Today's Date*
Q31

Signature (hold/click and sign with cursor)*