Name: _ _ _ _ _ _ Gender: _ _ _ _ _ Age: _ _ _ _ _ Class: _?
Tel: _ _ _ _ _ Emergency contact: _ _ _ _ _ _
Consultation Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Home address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Family interpersonal relationship: good? General? Not good? Not good?
Brothers and sisters ranking: only child, eldest son, daughter, last child, middle child?
Interpersonal relationship: good? General? Not good? Not good? _
Reason for visit: (tick the corresponding question)
Learning problems? Emotional problems? Disease obsession
Personality problems? Interpersonal relationship? Lack of feelings makes life difficult.
Other issues
Present the main symptoms
Anxiety, nervousness, insomnia, inferiority, hyperactivity, irritability, fear and depression.
Lack of self-confidence, memory loss and inattention.
Others:
physical condition
Normal dizziness, palpitation, loss of appetite, nausea, chest tightness, feeling cold and hot.
Others:
What is the extent of the current problem or symptom? Gentle? Medium? Is it serious?
Time and reason of occurrence _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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Consultant: _ _ _
_ _ _ _ year _ _ month? sun
XX psychological counseling room