OPD Assessment Form – Sukoon Clinic

New Patient Information

Name *

Age

Gender

Mobile *

Occupation

Marital Status

Education

Referred By

1. What is your main problem?

2. Symptoms (tick all that apply)

Mood Symptoms

Persistent sadness or low mood Loss of interest in previously enjoyable activities Crying frequently Feeling hopeless or helpless Feeling guilty or worthless Low confidence Lack of energy or fatigue Thoughts that life is not worth living Suicidal thoughts or self-harm thoughts

Anxiety Symptoms

Excessive worry or overthinking Nervousness Panic attacks Fear without any obvious reason Social anxiety Health anxiety Palpitations, sweating or trembling

OCD Symptoms

Repetitive unwanted thoughts Repetitive hand washing Repeated checking (door, gas, lock, etc.) Need for symmetry or exactness Counting rituals

Psychotic Symptoms

Hearing voices others cannot hear Seeing things others cannot see Feeling someone wants to harm or follow you Feeling someone is controlling your thoughts Feeling people are talking about you Suspiciousness Talking to yourself

Manic Symptoms

Extremely happy or excited mood Irritability Decreased need for sleep Talking excessively Racing thoughts Increased spending Risk-taking behaviour Increased sexual thoughts or behaviour

Attention & Behaviour

Poor concentration Forgetfulness Easily distracted Hyperactivity Restlessness Impulsive behaviour

Sleep Problems

Difficulty falling asleep Frequent awakening Early morning awakening Excessive sleep Nightmares

Substance Use

Other drugs

3. Duration of Symptoms

Less than 2 weeks 2 weeks–6 months More than 6 months More than 1 year

4. Severity

Mild Moderate Severe

5. What areas have the symptoms affected?

6. Have you consulted a Psychiatrist/Psychologist before?

Yes No

Diagnosis (if known)

Current Medicines

7. Past Psychiatric History

8. Medical History

Other

9. Family History

Relationship

10. Stress Factors

Relationship problems Financial problems Job stress Academic stress Family conflict Death of loved one Divorce/Separation

11. Risk Assessment

Have you ever attempted suicide?

YesNo

Are you currently having suicidal thoughts?

YesNo

Have you ever harmed someone?

YesNo

Do you become violent during anger?

YesNo

12. For Female Patients

Pregnant Breastfeeding Symptoms worsen before periods Not Applicable

Pre-Psychiatric OPD
Assessment Form

New Patient Information

1. What is your main problem?

2. Symptoms (tick all that apply)

3. Duration of Symptoms

4. Severity

5. What areas have the symptoms affected?

6. Have you consulted a Psychiatrist/Psychologist before?

7. Past Psychiatric History

8. Medical History

9. Family History

10. Stress Factors

11. Risk Assessment

12. For Female Patients

13. Any other concerns?

🌿 Sukoon Assistant

Pre-Psychiatric OPDAssessment Form

New Patient Information

1. What is your main problem?

2. Symptoms (tick all that apply)

3. Duration of Symptoms

4. Severity

5. What areas have the symptoms affected?

6. Have you consulted a Psychiatrist/Psychologist before?

7. Past Psychiatric History

8. Medical History

9. Family History

10. Stress Factors

11. Risk Assessment

12. For Female Patients

13. Any other concerns?

🌿 Sukoon Assistant

Pre-Psychiatric OPD
Assessment Form