PSYMED Intake & Registration Form

Name (Last, First): Click or tap here to enter text. Date of Birth: Click or tap here to enter text.
Gender: Click or tap here to enter text. Telephone number: Click or tap here to enter text.
E-mail: Click or tap here to enter text. Nationality(ies): Click or tap here to enter text.
Languages spoken: Click or tap here to enter text. I live in the Czech Republic YES NO
Address: Click or tap here to enter text. Employment status:
Student Full-time Part-time Not employed
Health Insurance company: Click or tap here to enter text. Relationship status:
Single Married / Partnered Divorced Widowed
Referral source: Self Friends or family Teacher or colleague Health professional (e.g. doctor, psychiatrist, etc.)
If health professional, please specify name and contact:

PHYSICAL HEALTH
During the past 7 days, how much have you been bothered by any of the following problems?
Item Not at all A little bit Somewhat Quite a bit Very much
1. Stomach or bowel problems 1 2 3 4 5
2. Back pain 1 2 3 4 5
3. Pain in your arms, legs, or joints 1 2 3 4 5
4. Headaches 1 2 3 4 5
5. Chest pain or shortness of breath 1 2 3 4 5
6. Dizziness 1 2 3 4 5
7. Feeling tired or having low energy 1 2 3 4 5
8. Trouble sleeping 1 2 3 4 5
Total Score:

9. If you have been suffering from any of the above problems, how long have you had them? Click or tap here to enter text.
(months/years)

10. How did the symptoms start? Gradual onset An event or accident

11. Please rate your pain. If you feel pain, how would you score the pain over the last 24 hours? (1 No pain, 10 Worst pain in my life)

1 2 3 4 5 6 7 8 9 10

11. How do your symptoms behave? Constant Comes and goes Getting worse

12. Have you received any examinations and/or treatment for the problem(s)? Yes No

MEDICAL HISTORY

1. Please list any significant illnesses, surgeries, or hospitalizations:

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2. Please list any medications you are taking:

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MENTAL HEALTH

In the last two weeks, have you experienced any of the following? (check all that apply)

Constant worry Low energy Change in appetite/eating

Easily irritated Overthinking Feeling sad
Change in sleep Not enjoying things you used to Sexual problems
Family problems Relationship issues Vocational/work problems

Unicare Medical Center, s.r.o., Na Dlouhém lánu 563/11, 160 00 Praha, +420 235 356 553, reception@unicare.cz, www.unicare.cz
PSYCHIATRIC HISTORY

1. Has anyone in your family suffered from mental health difficulties? Yes No
If yes, please describe:

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2. Have you had any thoughts of harming yourself or ending your life? Yes No
Did this include a suicide attempt? Yes No

3. Have you sought any psychiatric or psychological consultation before? Yes No

If yes, please write approx. period(s) of treatment:

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4. Have you had any history of addiction, or currently experience problem (alcohol, drugs, others)? Yes No
If yes, please specify:

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GOALS

1. Please choose which services you are interested in: (check all that apply)

Psychiatric medications One-time consultation

Psychotherapy Neuro/psychological testing
Group counselling Support groups and linkage to other resources
Psychosomatic diagnostics Psychosomatic treatment

2. In your own words, please describe what you would like to achieve from your appointment:

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I declare that to my best knowledge information given in this document are complete and true. I am aware of the fact that I take on a
partial responsibility for not providing any important information regarding my medical condition leading to an erroneous interpretation
of my medical condition, especially in cases when information not included in this document can be discovered only by specific
examination which is not a part of the examination. I declare that statements made in this document are a demonstration of my free will.
Statements and approvals given in this document were made without physical or emotional pressure which I confirm with my signature.
I, signed below, declare and confirm with my signature the following:

1. I agree with sending medical reports and laboratory results at the above-mentioned e-mail. I am aware of risk associated with ☐ YES ☐ NO
an electronic communication.

2. I agree with sending medical reports and laboratory results to third persons, notably to other providers of medical care involved ☐ YES ☐ NO
in a provision of medical care to my person, via an email. I am aware of risk associated with an electronic communication.

3. I have been informed by UMC of the principles and procedures in processing of my personal data as well as of the fact that the full UMC´s Privacy Policy
is available (in paper form) at the UMC reception and electronically on the website: www.unicare.cz. I have been informed by UMC and am aware that
my personal data and/or medical documentation may be disclosed to the health insurance company for the purposes of billing and payment for
medical services.
4. I have become familiar with the price list of UMC and have been informed about a scale and price of provided medical services to my person.
5. I acknowledge that this intake form does not guarantee the admittance to PSYMED’s care. In order to ensure the suitability of outpatient treatment, my
disposition will be confirmed after the written and verbal review of this request.

First time appointments & Cancellation conditions: We require the payment for the first examination/session in advance. Once an
appointment is scheduled, the time is fully reserved especially for you. We therefore kindly ask for a 24-hour notice should you need to
cancel. This is to allow the appointment time to be offered to another patient who may be on the waiting list. The full price of the session
will be charged for non-attendance or less than 24-hours notice of cancellation. For cancellation in between 24 to 48 hours to the
meeting, the half of the price will be charged.

I have read and understand the Cancellation conditions and agree to abide by its
guidelines.

Date: Patient’s name:

Unicare Medical Center, s.r.o., Na Dlouhém lánu 563/11, 160 00 Praha, +420 235 356 553, reception@unicare.cz, www.unicare.cz