Assessment Form
Patient Information
Name: ________________________________________________________________________
Age: ___________________Gender: ________________Date of Birth: ____________________
Contact Information: ____________________________________________________________
Address: ______________________________________________________________________
Date of Assessment: _____________________________________________________________
Emergency Contact
Name: ________________________________________________________________________
Relationship: __________________________________________________________________
Contact Number: _______________________________________________________________
1. Presenting Concerns
1. Primary reason for seeking assessment (client):
______________________________________________________________________________
______________________________________________________________________________
Primary reason for seeking assessment (Psychologist/Therapist):
______________________________________________________________________________
______________________________________________________________________________
2. How long have you experienced these concerns?
☐ Days ☐ Weeks ☐ Months ☐ Years
3. Current symptoms you are experiencing (check all that apply):
☐ Anxiety or excessive worrying ☐ Social withdrawal
☐ Depression or sadness ☐ Obsessive thoughts or compulsive behaviors
☐ Mood swings ☐ Paranoia or distrust of others
☐ Difficulty sleeping or nightmares ☐ Hallucinations (visual/auditory)
☐ Fatigue or low energy ☐ Delusions
☐ Loss of interest in activities ☐ Anger or irritability
☐ Difficulty concentrating or making decisions ☐ Thoughts of suicide or self-harm
☐ Panic attacks
☐ Other (please describe): _______________________________________________________
2. Psychological History
1. Have you been previously diagnosed with a psychological disorder?
☐ Yes☐ No
If yes, specify the disorder and date of diagnosis: ______________________________________
2. Are you currently receiving any psychological/psychiatric treatment?
☐ Yes☐ No
If yes, describe treatment (therapy, medication, etc.): ___________________________________
3. Have you been hospitalized for mental health issues?
☐ Yes☐ No
If yes, please provide details (when, reason): _________________________________________
4. Have you ever attempted suicide or self-harm?
☐ Yes☐ No
If yes, please provide details: ______________________________________________________
3. Medical History
1. Do you have any chronic medical conditions?
☐ Yes☐ No
If yes, specify: _________________________________________________________________
2. Are you currently taking any medications?
☐ Yes ☐ No
If yes, list medications: __________________________________________________________
3. Do you have any history of head injuries or neurological conditions?
☐ Yes☐ No
If yes, please provide details: ______________________________________________________
4. Family and Social History
1. Do you have a family history of psychological disorders?
☐ Yes☐ No
If yes, specify the disorder(s) and relationship: ________________________________________
2. Current living situation (alone, with family, etc.):
3. Do you have a history of substance use (e.g., alcohol, drugs)?
☐ Yes☐ No
If yes, please provide details: ______________________________________________________
4. Have you experienced any significant life changes or stressors recently (e.g., trauma, divorce, financial
problems)?
☐ Yes☐ No
If yes, please describe: ___________________________________________________________
5. Cognitive and Emotional Functioning
1. Have you noticed any recent changes in memory, attention, or concentration?
☐ Yes☐ No
If yes, please describe: ___________________________________________________________
2. Do you experience intense or uncontrollable emotions?
☐ Yes☐ No
If yes, describe the emotions and situations that trigger them: ____________________________
3. Do you have trouble managing stress?
☐ Yes☐ No
If yes, how do you usually cope with stress? __________________________________________
6. Risk Assessment
1. Have you experienced thoughts of harming yourself or others?
☐ Yes☐ No
If yes, please describe: ___________________________________________________________
2. Have you engaged in self-harm or violence towards others?
☐ Yes☐ No
If yes, provide details (when, how): _________________________________________________
3. Are there any immediate risks to your safety or the safety of others?
☐ Yes☐ No
If yes, explain: _________________________________________________________________
7. Functional Impact
1. How have your symptoms affected your daily life? (check all that apply):
☐ Work or school performance ☐ Social activities
☐ Relationships (family, friends, partners) ☐ Self-care (e.g., hygiene, eating)
☐ Physical health
☐ Other: _____________________________________________________________________
2. On a scale of 1-10, how would you rate the impact of your symptoms on your overall quality of life?
_______/10
8. Additional Information
Is there anything else you feel is important for us to know about your mental health?
Therapist Notes:
Initial Diagnosis/Observations/Tentative Diagnosis: ___________________________
Suggested Treatment/Next Steps: _____________________________________________
Referral Needed: ☐ Yes ☐ No
If yes, referred to: _________________________________________________________
Patient Signature: ____________________________
Date: ____________________
Clinical Psychologist Signature: __________________________
Date: ____________________
Dr. Imtiaz Ahmed
Senior Medical Officer
Police Line Dispensary Islamabad
