YS Dr. Yeshwant Solanki Neuropsychiatrist
OPD Assessment

Pre-Psychiatric OPD
Assessment Form

Please fill in your details before the consultation with Dr. Yeshwant Solanki — everything will remain confidential. Please fill carefully as this form can only be filled once.

New Patient Information

1. What is your main problem?

2. Symptoms (tick all that apply)

Mood Symptoms

Anxiety Symptoms

OCD Symptoms

Psychotic Symptoms

Manic Symptoms

Attention & Behaviour

Sleep Problems

Substance Use

3. Duration of Symptoms

4. Severity

5. What areas have the symptoms affected?

6. Have you consulted a Psychiatrist/Psychologist before?

7. Past Psychiatric History

8. Medical History

9. Family History

10. Stress Factors

11. Risk Assessment

12. For Female Patients

13. Any other concerns?

🔒 Everything will remain confidential — only the clinic team will have access.