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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