Adult Pre Consultation Questionnaire
Please complete this questionnaire if you are an adult seeking consultation for yourself
1) Personal Details and Contact Information
Name
Date of Birth
(dd/mm/yyyy)
Gender
Male
Female
Postal Address
Telephone Number
Email Address
2) Registration with a General Practitioner
Who is your GP?
Postal Address
Telephone Number
I give consent for you to contact my GP
3) Tell me about the problem
Briefly describe the problem for which you are seeking consultation. You can write whatever you feel would help me understand your situation, but do try to end by summarising your top three concerns.
What do you hope the consultation will do or achieve, in relation to the concerns you have described above?
Have you tried anything else to improve matters?
Yes
No
If so, please give some details
Are any other professionals involved in helping you?
Yes
No
If so, please give some details
Have you suffered any trauma, important change or loss ?
Yes
No
If yes, please describe
4) Health Background
Do you have any current or previous health problems?
Yes
No
If so has this involved any regular medication or treatment appointments (please outline)?
Do you have any current or previous known mental health problems?
Yes
No
If so has this involved any regular medication or treatment appointments (please outline)?
How would you describe your sleep, appetite and mood state from day to day?
5) Home and Employment Situation
Briefly describe your home circumstances (e.g. Married, divorced or single? Who else lives at home? How happy are you with where you live?)
Briefly describe your employment status, with details of the responsibilities and hours this involves.
What are your hopes for the future?
6) General Information
Anything else you feel the consultant should know, that hasn’t already been asked about?
7) Payment Preferences
If consultations are arranged, I would like to pay for sessions in the following way
Credit Card
Sterling Cheque
Postal Order
Bank Transfer