Consultation - Pharmaceutra

Anxiety

Anxiety disorders encompass various conditions characterised by excessive fear or worry, including generalised anxiety disorder, panic disorder, and social anxiety disorder. Anxiety disorders are among the most common mental health conditions and can include generalised anxiety disorder (GAD), panic disorder, social anxiety disorder, and specific phobias. Symptoms can include restlessness, rapid heartbeat, difficulty concentrating, and a feeling or unease or worry. Everyone has feelings of anxiety at some point in their life.

Please fill out the form below so that our clinicians can determine if the treatment will be suitable for you to take.

1 About Your Health

Your health and safety are our top priorities. Please provide accurate and complete information during your consultation so we can recommend the most appropriate treatment for you.

What is your date of birth?

What is your gender?

Female

Male

Do you have any known allergies?

Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

If yes, please detail them here, otherwise please type N/A

Are you currently taking any medications?

If yes, please detail them here, otherwise please type N/A

Have you had any surgeries in the past year?

If yes, please detail them here, otherwise please type N/A

Do you smoke?

Do you consume alcohol?

If yes, how much a day/weekly?

What is your typical diet like? (e.g., balanced, high-fat, spicy foods)

How often do you exercise? (e.g., daily, weekly, rarely, never)

2 About Your Condition

Please provide accurate and honest details during your consultation. This helps us offer the safest and most effective treatment for you.

Who diagnosed your anxiety? (e.g., psychiatrist, general practitioner)

Please provide more detail here

How long have you been experiencing anxiety symptoms?

Please provide more detail here

Have you had any recent tests or assessments to evaluate your condition? (e.g., psychological evaluation, blood tests)

How often do you experience anxiety symptoms? (e.g., daily, weekly, occasionally)

Daily

Weekly

Occasionally

What are the common symptoms you experience? (e.g., excessive worry, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbances)

Please provide more detail here

Are your symptoms triggered by specific situations or events? (e.g., social situations, work-related stress)

Have you been prescribed medication for anxiety before?

Are you currently taking any medication for anxiety?

Have you experienced any side effects from your current or past anxiety medications?

Have you tried any non-medication treatments for anxiety? (e.g., therapy, mindfulness, exercise, dietary changes)

Have you consulted with a healthcare provider about your anxiety?

3 The Agreement and Consent

Please read the Agreement and Consent statements carefully during your consultation. They contain important information to help you stay informed and safe throughout your treatment.

Understanding of Risks

Yes

Medical Guidance

Yes

Consent to Share Information

Yes

Confirmation

Yes

1 About Your Health
2 About Your Condition
3 The Agreement and Consent

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Assessment for Anxiety

Anxiety

1 About Your Health

What is your date of birth?

What is your gender?

Do you have any known allergies?

Yes

Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

Yes

Are you currently taking any medications?

Yes

Have you had any surgeries in the past year?

Yes

Do you smoke?

Yes

Do you consume alcohol?

Yes

What is your typical diet like? (e.g., balanced, high-fat, spicy foods)

Yes

How often do you exercise? (e.g., daily, weekly, rarely, never)

Yes

2 About Your Condition

Who diagnosed your anxiety? (e.g., psychiatrist, general practitioner)

How long have you been experiencing anxiety symptoms?

Have you had any recent tests or assessments to evaluate your condition? (e.g., psychological evaluation, blood tests)

Yes

How often do you experience anxiety symptoms? (e.g., daily, weekly, occasionally)

What are the common symptoms you experience? (e.g., excessive worry, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbances)

Are your symptoms triggered by specific situations or events? (e.g., social situations, work-related stress)

Yes

Have you been prescribed medication for anxiety before?

Yes

Are you currently taking any medication for anxiety?

Yes

Have you experienced any side effects from your current or past anxiety medications?

Yes

Have you tried any non-medication treatments for anxiety? (e.g., therapy, mindfulness, exercise, dietary changes)

Yes

Have you consulted with a healthcare provider about your anxiety?

Yes

3 The Agreement and Consent

Understanding of Risks

Medical Guidance

Consent to Share Information

Confirmation

Assessment Progress

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