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Therapy
Adults
ERP for OCD for Adults
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EMDR
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EMDR for Attachment
EMDR for Performance
CBT
CBT for Pregnancy
CBT for Sleep – CBT-i
CBT for Performance
CBT for Anxiety
Trauma-Focused CBT
Children and Young People
Children & Adolescent Therapy Online
OCD – ERP for Children & Young People
CBT Children and Young People
ADHD Assessments
Children and Young People ADHD Assessment
Adult ADHD Assessment
For Parents/Carers
Neuro-Affirming Parenting Sessions
Non-Violent Resistance (NVR) for parents
Therapist Corner
Supervision
Resources
Workshops
Corporate
Blog
Contact
Fees
Testimonials
Pre-medication questionnaire
General Information
Patient Name:
(Required)
Patient Date of Birth:
(Required)
Clinician Name
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Choose an option
Ryan Williams
Pre-Medication Checklist
What are your treatment goals?
(Required)
What is your sleep like at present?
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What is your diet like?:
(Required)
Please tell us about your current alcohol consumption and any substance use at present:
(Required)
Medical History
Do you have any current physical health conditions?:
(Required)
Yes
No
Please provide further details for physical health conditions
Do you currently take any prescribed or over the counter medications?
(Required)
Yes
No
Please provide further details of Drug name, Dose, and Frequency
What is your current weight?
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What is your current height?
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What is your current blood pressure? ( Please provide both systolic and diastolic readings )
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What is your current pulse rate? (BPM)
(Required)
Cardiovascular Assessment
Do you have any history of heart disease, or previous cardiac surgery?
(Required)
Yes
No
If you do, please provide further details around this.
Is there any family history of diagnosed heart disease or suspected heart disease?
(Required)
Yes
No
If you do, please provide further details around this.
Is there any history of sudden death in an immediate relative under the age of 40?
(Required)
Yes
No
If you do, please provide further details around this.
Do you experience any shortness of breath or exertion comparative to your peer group?
(Required)
Yes
No
If you do, please provide further details around this.
Have you ever Fainted on exertion in response to fright comparative to peer group?
(Required)
Yes
No
If you do, please provide further details around this.
Do you experience any palpitations that are rapid, regular and start/stop suddenly?
(Required)
Yes
No
If you do, please provide further details around this.
Do you suffer any Chest pain suggesting cardiac origin?
(Required)
Yes
No
If you do, please provide further details around this.
Do you have any Signs of heart failure?
(Required)
Yes
No
If you do, please provide further details around this.
Have you ever had a murmur heard on cardiac examination?
(Required)
Yes
No
If you do, please provide further details around this. (Diagnosis and Treatment term details)
Medical History - Current and Past
Do you have any diagnosed mental health conditions?
(Required)
Yes
No
Please provide further details (Diagnosis and Treatment term details)
Have you ever had any treatment for mental health conditions?
(Required)
Yes
No
Please provide further details (Diagnosis and Treatment term details)
Do you experience any Hypertension?
(Required)
Yes
No
Please provide further details (Diagnosis and Treatment term details)
Have you ever suffered from Epilepsy/seizures?
(Required)
Yes
No
Please provide further details (Diagnosis and Treatment term details)
Do you have any issues relating to Hyperthyroidism?:
(Required)
Yes
No
Do you have or family history of Glaucoma?:
(Required)
Yes
No
Please provide further details (Diagnosis and Treatment term details)
Have you ever suffered any Tics or Tourette’s syndrome?
(Required)
Yes
No
Please provide further details (Diagnosis and Treatment term details)
Are you Pregnant or breastfeeding?
(Required)
Yes
No
Have you ever experienced Vasculitis?
(Required)
Yes
No
Do you have any allergies?
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No
Consent
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I consent and agree to Mental Health Assessment/Treatment
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