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Biopsychosocial Form

  • CLIENT BACKGROUND INFORMATION
  • Family Details
  • INFORMATION ON GENERAL HEALTH CARE AND MENTAL HEALTH
  • INFORMATION ON GENERAL HEALTH CARE AND MENTAL HEALTH
  • INFORMATION ON GENERAL HEALTH CARE AND MENTAL HEALTH

Client Background Information

Name:

Identification card no:

Email

Permanent Address:

Current Address:

Date of Birthday:

Gender:

Nationality:

Religion:

Contact Number:

What is the reason you get counseling?

Have you ever sought counselling and Session Duration?

Family Information

Number of siblings

Father/ guardian's occupation

Mother's/ guardian's occupation

Household income

Parental marital status

Individual to be contacted during emergency

Name

Relationship

Address

Mobile Number

EDUCATION BACKGROUND

Your highest academic achievement

Your involvement in sports activities

Involvement in Clubs/ Associations/ Uniform Units

GENERAL HEALTH CARE AND MENTAL HEALTH

Have you attended any counselling session/guidance/ psychotherapy?

Have you took any prescribed medicines from any professional?

Have you been prescribed with any medicines related to psychiatric treatment?

Based on 5-scale below, please state your level of physical health.

Based on 5-scale, please state your satisfaction on your sleep quality.

How often do you exercise in a week?

Please state your eating behavior

Encountered any Situations

Have you encountered any situations as below:

1. The lost of significant person in life

Period of time

2. Sadness

Period of time

3. Depression

Period of time

4. Anxiety

Period of time

5. Panic attack

Period of time

6. Phobia

Period of time

GENERAL HEALTH CARE AND MENTAL HEALTH

Substance Abuse

Have you took any of these substances. Please state if it is related.

1. Drug

Period of time

2. Tobacco

Period of time

3. Substance

Period of time

4. Alcohol

Period of time

5. Pills abuse

Period of time

6. State

Period of time

Misconduct

Have you ever involved in any misconducts below:

1. Gambling

Period of time

2. Stealing

Period of time

3. Watching pornography

Period of time

4. Bullying

Period of time

5. Beating / cause injury to other person

Period of time

6. Cause damage to other’s property

Period of time

7. Threaten others

Period of time

8. Sexual misconduct

Period of time

GENERAL HEALTH CARE AND MENTAL HEALTH

Do you have any chronic disease?

Specify

Do you have any girlfriend/ boyfriend?

If yes, based on 10-scale below, state your level of satisfaction in your relationship.

I have a strong religious conviction

Based on 10 scale, state your level of satisfaction in your family relationship.

Individual in your life

A significant individual in your life.

Name

Relationship with that individual:

State 3 of your strengths:

1.

2.

3.