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Pre-medication questionnaire

General Information

Pre-Medication Checklist

Medical History

Do you have any current physical health conditions?:(Required)
Do you currently take any prescribed or over the counter medications?(Required)

Cardiovascular Assessment

Do you have any history of heart disease, or previous cardiac surgery?(Required)
Is there any family history of diagnosed heart disease or suspected heart disease?(Required)
Is there any history of sudden death in an immediate relative under the age of 40?(Required)
Do you experience any shortness of breath or exertion comparative to your peer group?(Required)
Have you ever Fainted on exertion in response to fright comparative to peer group?(Required)
Do you experience any palpitations that are rapid, regular and start/stop suddenly?(Required)
Do you suffer any Chest pain suggesting cardiac origin?(Required)
Do you have any Signs of heart failure?(Required)
Have you ever had a murmur heard on cardiac examination?(Required)

Medical History - Current and Past

Do you have any diagnosed mental health conditions?(Required)
Have you ever had any treatment for mental health conditions?(Required)
Do you experience any Hypertension?(Required)
Have you ever suffered from Epilepsy/seizures?(Required)
Do you have any issues relating to Hyperthyroidism?:(Required)
Do you have or family history of Glaucoma?:(Required)
Have you ever suffered any Tics or Tourette’s syndrome?(Required)
Are you Pregnant or breastfeeding?(Required)
Have you ever experienced Vasculitis?(Required)
Do you have any allergies?(Required)
Consent(Required)
I agree for this form to be sent to the Associated Therapist(Required)
Check terms and condition(Required)
Online CBT and EMDR therapist
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