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Neuro-Diagnostic Patient Questionnaire
Name
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Marital Status
Married
Single
Partner
Divorced
Widowed
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Email Address
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Date of Birth
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Year
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2012
2013
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Employment Status
Employed - Full Time
Employed - Part Time
Employed - Casual
Student
Self-employed
Retired
Other (e.g. Pensioner)
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Occupation (current or previous)
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Phone Number
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A Perfectionist?
Yes No
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Living Arrangements
Live with Parents
Live Alone
Live with Partner
Live with Carer
Live in Share House
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Please upload a photo of yourself
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{Self Description:caption}
{Self Description:body}
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{Self Description:description}
Artistic & Creative?
Yes
No
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Innovative (comes up with new ideas quickly)?
Yes
No
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Shy?
Yes
No
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Over-reactive?
Yes
No
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A Day-dreamer?
Yes
No
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A Lateral Thinker (can 'think outside the box')?
Yes
No
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Moody?
Yes
No
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Restless (constantly moving, hair or finger fiddling, etc)?
Yes
No
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Hypersensitive to the environment (noise, touch, etc)?
Yes
No
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Intelligent?
Yes
No
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Easily Overwhelmed?
Yes
No
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Hyper-vigilant (i.e. always on the lookout for possible threats / dangers)?
Yes
No
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Driven?
Yes
No
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Angry?
Yes
No
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Inconsistent in relationships, performance and commitments?
Yes
No
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Stubborn?
Yes
No
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A negative predictor (predicts what can go wrong)?
Yes
No
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Easily Bored?
Yes
No
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An Under-achiever (i.e. given your intelligence & creativity)?
Yes
No
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Is there a 'negative voice' in your head that criticises you or brings you down?
Yes
No
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Do you sense you need constant reassurance? (i.e. to feel good about yourself)
Yes
No
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Stressed or anxious upon waking, or soon after? (i.e. immediately think about the negative things that could happen or possibly go wrong in your day!)
Yes
No
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Is your mind hardly ever quiet?
Yes
No
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Do you have times, when completing tasks that others can do easily, are overwhelming or difficult for you?
Yes
No
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When asked a question, does your mind tend to go blank?
Yes
No
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When asked a question, do you find you have too many answers in your head to answer quickly?
Yes
No
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Over-reactive (i.e. your 'fight or flight' mechanism is ready to fire!)?
Yes
No
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Do you ruminate excessively (go over and over negative thoughts in your head?)
Yes
No
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When asked a question, do you feel it takes too much energy to answer?
Yes
No
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Do you see the world negatively ?(i.e. the cup ½ empty, rather than ½ full)
Yes
No
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Three words to describe how YOU see yourself?
1. 2. 3.
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What is it that make you seek help, or that causes you the most problems in your life, that you would like to address or change?
1.
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2.
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3.
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4.
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Recent Life Events
In the past 2 years, have you experienced a significant injury, loss, relationship break-up or change in circumstances (e.g. unemployment, retirement, relocation?)
Yes
No
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If yes, please describe
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List 3 very significant things (good first, then bad second) that have occurred in your life. (Remember, what is significant to YOU, not necessarily significant to others.)
3 good things
1. 2. 3.
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3 bad things
1. 2. 3.
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Family of Origin
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Father Age
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Most of us show characteristics similar to our parents (e.g. laid-back, always busy, worrier, etc.)
Who do you think you are most like?
Mother
Father
Both
Neither
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How are you like them? (Consider temperament, mood, energy, etc.)
Mother: Father:
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What 3 words would you use to describe your relationship with your:
Mother
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Father
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Who is the most conflictual character in your life? (i.e. the one that always criticised & put you down?)
Mother
Father
Sibling
Other (e.g. Grandparent, Teacher etc.)
None
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Present Family/Relationship
Partner; Spouse or boy/girlfriend's First Name
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Partner's Age
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Partner Occupational History
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Child 1 First Name
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Child 1 Comments
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Child 2 First Name
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Child 2 Age
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Child 2 Comments
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Child 3 First Name
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Child 3 Age
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Child 3 Comments
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Child 4 First Name
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Child 4 Age
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Child 4 Comments
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Child 5 First Name
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Child 5 Age
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Child 5 Comments
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Do you have any significant medical conditions such as diabetes, thyroid disease, epilepsy, cancer, etc?
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Medical History
Obstetric / Birth History
During her pregnancy with you, did your mother experience:
Physical Problems (e.g. diabetes or toxaemia)?
Yes
No
Unknown
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Mental Health Problems (e.g. anxiety or depression)
Yes
No
Unknown
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Significant Stress (e.g. the loss of a loved one)
Yes
No
Unknown
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Significant Trauma (e.g. being involved in a car crash)?
Yes
No
Unknown
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Were you born at full term (i.e. 40 weeks)?
Yes
No
Unknown
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If no, how many weeks premature were you?
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Was yours an uncomplicated, normal birth?
Yes
No
Unknown
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Was the labour extremely rapid (3 hours or less)?
Yes
No
Unknown
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Was the labour prolonged and very difficult?
Yes
No
Unknown
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Were you born by emergency caesarean section?
Yes
No
Unknown
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Was your birth assisted with forceps or vacuum extraction?
Yes
No
Unknown
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During the pregnancy, labour, delivery (or after) was there any foetal distress?
Yes
No
Unknown
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At the delivery, were there breathing problems or the need for resuscitation?
Yes
No
Unknown
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At delivery was the cord tightly around the neck?
Yes
No
Unknown
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Were you covered with meconium (green foetal bowel motion) at birth?
Yes
No
Unknown
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Were you separated from your mother directly after birth? (i.e. transferred to neonatal ICU or special nursery)
Yes
No
Unknown
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During the postnatal period was there any infections or other problems?
Yes
No
Unknown
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Past History: Head Injury or Brain Insult.
Have you ever experienced?
Concussion? (even mild concussion!)
Yes
No
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A skull fracture?
Yes
No
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Electrocution?
Yes
No
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Sever whiplash injury?
Yes
No
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A 'fit' or seizure? ( i.e. after head injury or drug withdrawal ...etc)
Yes
No
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Knocked unconscious?
Yes
No
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Resuscitation? (i.e.post-drowning, severe blood loss, cardiac arrest.....etcv)
Yes
No
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Symptoms related to Brain Injury or Insult
Do you have times when things, people or places seem strangely unfamiliar, despite knowing this not the case?
Yes
No
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Brain infection or inflammation? (i.e. meningitis, encephalitis, autoimmune disease ...etc.)
Yes
No
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Do you have déjàvu more than twice a year?
Yes
No
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At times do you have a quick temper, "short fuse" or “spit the dummy”over things that don't really matter?
Yes
No
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Do you suffer from road rage?
Yes
No
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Do you misinterpret comments as negative when they are not?
Yes
No
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Do you have times where you become angry or enraged?
Yes
No
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Do you have periods of spaciness or 'brain fog'?
Yes
No
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Do you have periods of panic and/or fear for no specific reason?
Yes
No
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Do you experience visual changes, such as seeing shadows or objects changing shape?
Yes
No
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Do you notice movements or flashes in your peripheral vision, and on looking find there is nothing there?
Yes
No
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Would you say that you're highly sensitive to criticism or even mildly paranoid?
Yes
No
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Do you have periods of forgetfulness or memory problems?
Yes
No
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Do you have a 'short fuse' or periods of extreme irritability?
Yes
No
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Have you experienced headaches or abdominal pains (even as a child), where no cause is often found?
Yes
No
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Do you have a history of physical abuse, being punched, hit over the head, particularly with the open hand?
Yes
No
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Have you played any sport, where your head has undergone trauma (you do not have to have been concussed or knocked out: i.e. boxing, AFL, soccer, rugby, martial arts or boxing)
Yes
No
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Do you have dark thoughts, which may involve suicide or homicidal ideas; even though you know you would never act on them?
Yes
No
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Have you at times experienced some unusual phenomena (see or hear things) and just passed it off as "being weird"?
Yes
No
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Do you experience any dream phenomena, where you have a dream and a day or so later, you find it happening?
Yes
No
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Sleep Analysis
Do you experience disturbed sleep,wake up unrested and feel tired and irritable during the day?
Yes
No
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Do you "doze off" or fall asleep at times where others wouldn't? (i.e. at the meal table, watching TV, driving or virtually anywhere!)
Yes
No
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Do others complain about your snoring?
Yes
No
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Do you have difficulty breathing through your nose or mouth?
Yes
No
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Do you doze (i.e. 'drop-off' or snooze) during the day, when others would not?
Yes
No
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Do you suffer from frequent nightmares?
Yes
No
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Has you ever been diagnosed, or someone thought you may have sleep apnoea? (i.e. noticed you stop breathing for short spells when asleep)
Yes
No
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Do you have "jumpy"and "twitchy" legs when going to sleep at night? (i.e. restless leg syndrome)
Yes
No
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Illicit Drug Use
In the last three months, have you taken any illicit drugs?
Yes
No
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If 'yes', please state what substance/s you have taken
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Self Harm
Have you self-harmed (e.g. cutting, burning, hair pulling, head-banging (as child or adult)?
Yes
No
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If 'yes', please comment
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Social Activity and Networking
Are you active in any social networking media (i.e. Facebook, Twitter, SnapChat)?
Yes
No
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How many hours a day do you spend interacting on the web?(i.e. not including at work)
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How many friends do you have on your profile?
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Are you 'addicted' to using social media, the internet or your mobile phone?
Yes
No
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Personal Interests
Do you have tattoos, body piercings, or body adaptations (e.g. branding, insertions) or other body art? (excluding earrings)
Yes
No
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Please record your main interests and/or hobbies (e.g. sport, travel, music, etc.)
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Educational History
The following relates to experiences at school (particularly secondary school).
Was it a good experience?
Yes
No
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Were you academically successful?
Yes
No
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Did you have several friends?
Yes
No
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Were you bullied?
Yes
No
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Were you known as the 'class clown'?
Yes
No
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Did you have learning problems/difficulties?
Yes
No
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Were you interested in study?
Yes
No
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Did you find you had to work harder than others to get satisfactory marks?
Yes
No
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Were you good at extracurricular activities?
Yes
No
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Did your school reports comment; "you could have done better had you applied yourself, paid more attention or completed tasks (such as homework) on time"?
Yes
No
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Please comment on your years at school (e.g. “I was never interested in study", "I was only about my social life" or sport etc)
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University/Tertiary education or Trade Qualifications (please include partially completed courses)
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Employment History
1. 2. 3.
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Since leaving school, have you changed jobs, study courses or employment numerous times?
Yes
No
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How would others see or describe you?
1. 2. 3.
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Have you served in the armed forces?
Yes
No
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Are you happy with your job? (All things considered)
Yes
No
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Any additional comments regarding your current employment, job satisfaction or what you might wish to do!?
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Current Medication
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Treatment History
Have you ever 'sought help' regarding your mental health from any of the following?
Psychiatrist
Yes
No
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How many?
1
2
3
4
5+
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Psychologist, therapist or counsellor
Yes
No
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How many?
1
2
3
4
5+
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General Practitioner
Yes
No
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Please comment on your experience, satisfaction level or outcome from seeing mental health professionals
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Have you ever engaged in therapy? (CBT or Mindfulness CBT; Dynamic Psychotherapy etc. Please comment on the outcome of your therapy or any other comment.
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Do we have your permission to use your data (without disclosing your name or personal details) for lectures, research or statistics?
Yes
No
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Thank you for taking the time to complete the Neuro-Diagnostic Centre New Patient Questionnaire.
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