Asif Clinics
Mental health department
1. Personal Information:
- Name: _______________________________________________________________
- Age: _______________________________________________________________
- Date of birth: ______________________________________________________________
- Gender: _______________________________________________________________
- Contact information: _________________________________________________________
2. Presenting Concerns:
- What brings you in today?
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- Can you describe the problems or symptoms you are experiencing?
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- When did these problems/symptoms start?
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- Have they been getting better, worse, or staying the same?
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3. Background Information:
- Medical history (including past and current illnesses, injuries, surgeries):
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- Medications you are currently taking:
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- Allergies:
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- Family medical history (especially mental health conditions):
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4. Psychosocial History:
- Educational background:
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- Employment history:
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- Marital/relationship status:
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- Living situation (alone, with family, etc.):
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- Support system (family, friends, etc.):
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- Significant life events or recent changes:
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- Substance use history (alcohol, tobacco, drugs):
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- Legal history (if applicable):
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5. Mental Health History:
- Previous diagnoses (if any):
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- Previous treatments (therapy, medication):
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- Hospitalizations (if any):
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- Suicidal thoughts or attempts (history and current status):
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- History of self-harm or injury (if applicable):
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- Family history of mental health issues:
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6. Psychosocial Stressors:
- Recent or ongoing stressful situations:
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- Relationship difficulties:
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- Work or school-related stress:
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- Financial difficulties:
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- Traumatic events:
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7. Coping Strategies:
- How do you typically cope with stress?
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- Hobbies or activities that you find enjoyable or helpful:
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- Supportive relationships or social activities:
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8. Additional Questions:
- Are there any cultural or religious factors that may be relevant to your treatment?
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- Are there any other concerns or information you think is important for me to know?
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