Name:

Gender:
Age:
Where do you live (country)?:
E-mail:
Skype (in case you want to get the extra Skype service):
1.- In which stages of your life have you had mental health problems?
Childhood

Teenager

Adult life

Late life

2.- Answer yes / no . If the problem isn't present right now, but you feel that the problem has been
important during your life, answer YES.
I feel generally sad.
I don't sleep well.
I have nightmares.
Anxiety is a problem for me.
I have panic attacks often.
It's hard for me to concentrate.
I think about suicid often.
I have tried in the past to commit self-murder.
I have periods in my life when I feel too much energy, do too many things, or ar generally too
active. I feel good or very good during those episodes.
I have injured myself because of anxiety sometime in my life.
I feel that I'm unstable, things feel white one moment and black the next one.
I have had problems with substance abuse during my life.
I'm generally unsatisfied with my body.
I have problems with my weight, and it's hard for me to eat properly.
I have problems remembering things.
I see or hear things that aren't real.
I have been involved in crimes during my life.
I get into fights often.

There's an active conflict in my life.

I smoke.
I remember often a situation that was traumatic (sexual abuse, psychological abuse, an accident,
war, etc.)
3.- Describe shortly every YES- answer in the question number 2.

4.- Do you have any blood-relatives who have mental health problems? Which diagnosis? If you
don't know what is the name of the disease, can you describe how they are a little bit (shortly)

5.- What psychiatric medicines have you tried?

Name

Date of start

Date of finish

Reason to take it

Reason to not take it

anymore

Reason to take it

How does it feel

6.- What psychiatric medicines do you take actually?

Name

Date of start

Date of finish

7.- How do you feel your actual treatment helps you? Something that you wonder about it? Side
effects? Is there something you would like to change?

8.- Do you have any somatic diseases (problems in your body, for example diabetes, high blood
pressure...)? Do you take any medicines that are not from psychiatry? When was the last time you
went to a general doctor? Do you have thyroid problems?

9.- When was the last time you had contact with a mental health proffessional? What changes did
you do? What plan? Did you get a diagnosis? Do you get some contact every week (for example
psychotherapy)?

10.- Do you want to get help with something specific?

11.- Something we forgot to ask? Something you want to say? Write all you want. But please try to
be as direct as possible.