Background Information — U Maganlal Psychology Inc.

Patient Details

Name of patient

Date of birth

Gender

Home language

Highest education

Employment

Marital status

Handedness

Referral

Referred by (name)

Referrer contact number

Reason for referral

When did you first notice the changes?

Was it sudden or gradual?

Triggering illness/injury/significant event?

If yes, briefly describe the triggering event

Briefly describe the problems relating to the referral (major complaints)

Payment

Payment option

Family Structure

Specific to the person being assessed. For an elderly person, parents’ and siblings’ details are still useful. Add lines as needed.

RelationAge / Year of birth / DeceasedHighest education / qualificationStatus

Father

Mother

Siblings

SiblingAge / Year of birth / DeceasedHighest education / qualificationStatus

Spouse / Partner

SpouseAge / Year of birth / DeceasedHighest education / qualificationStatus

Children

ChildAge / Year of birth / DeceasedHighest education / qualificationStatus

Other family members

RelationAge / Year of birth / DeceasedHighest education / qualificationStatus

Living Circumstances & Interactions

Current living conditions

Home ownership

Lives alone or shared

Level of social interaction

Hobbies

Financially independent?

Opinion of strong and weak features (cognitive, emotional or personality)

Medical Background

Specific to the person being assessed. For each area, indicate whether it applies, add any details, and estimate when it began. If unsure, choose “Unsure”.

Current / Chronic Medication

List current and past chronic medication. Add or remove lines as needed. Tick all times of day that apply.

Name of medicationDosageMorning / Noon / NightOnset

Educational & Occupational Background

Establishing life experience. A CV may be attached (Attachments tab) and referred to instead.

Highest level achieved at school

Were there any failures?

If yes, please give details

Post-school Education / Certifications / Diplomas / Degrees

QualificationInstitutionYear

Work History

Role / OccupationEmployerYears

Athletics / sports / fitness (school & post-school)

Vocational / occupational summary

Post-work activities

Any other factors (personality / psychological / emotional / family-related), or anything not asked above

If completed by a relative or friend

Your name

Relationship to the patient

Your contact number

Supporting Documents

If available, it is helpful to have the following ready — for example a CV, relevant medical reports, scan/MRI results, referral letters, or previous assessments.

For your privacy: please bring these documents to your appointment (or hand them in at the practice) rather than emailing them — email is not a secure channel for personal or medical information.

Review & Print

Please review your answers in the previous tabs, then print (or save as a PDF) a clear copy to bring to your appointment.

I confirm that the information provided is accurate and complete to the best of my knowledge.

For your privacy: please print (or save as a PDF) and bring this completed form to your appointment, or hand it in at the practice. To protect your personal and medical information, please do not email the completed form — email is not a secure channel for these details.