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Your Medical Evaluation

This evaluation is unique to you, as questions change dynamically based on your answers. This removes redundant, time-consuming questions, and focuses primarily on your medical history and symptoms that help our therapists determine the best possible treatment for you.

By clicking on begin you have acknowledged that you have read and understood our Privacy Policy and Terms Of Use., and consent to the collection, use and disclosure of your personal data to Noah Health Pte Ltd. for the purposes set out in the Notice.

Name *

First

Last

Full name as per your NRIC or Passport

Date of birth *//

Checkbox Items

First Item
Second Item
Third Item

I found it hard to wind down (relax).

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

Please read each statement and select the option which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

I was aware of dryness of my mouth.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I couldn't seem to experience any positive feeling at all.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion).

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I found it difficult to work up the initiative to do things.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I tend to over-react to situations.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I experienced trembling (e.g. in the hands).

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I felt that I was using a lot of nervous energy.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I was worried about situations in which I might panic and make a fool of myself.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I felt that I had nothing to look forward to.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I found myself getting agitated.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I found it difficult to relax.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I felt down-hearted and blue.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I was intolerant of anything that kept me from getting on with what I was doing.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I felt I was close to panic.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I was unable to become enthusiastic about anything.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I felt I wasn't worth much as a person

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I felt that I was rather touchy.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat).

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I felt scared without any good reason.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

I felt that life was meaningless.

Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time

If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people? *

Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult

Are any of these triggers for your mental health condition? It’s totally normal for common situations in your life to cause an increase of symptoms and stress. *

Medical diagnosis
Worries or negative thoughts about the future
Social situations
Recent relationship issues
Things associated with a traumatic event
Fear of a panic attack
Unsure
Other
Nothing triggers my mental health condition

Please describe the trigger/s for your mental health *

This information helps your therapist better understand you better.

Is there any new or recent life event that may be impacting how you are feeling? Select all that apply. *

Life event or transition
Family or relationship problems
School or career stressors
Loss of a friend or a family member
Medical conditions
I have not had a new event or stress in my life recently
None of the above

Please describe the new or recent life event/s that may be impacting how you are feeling. *

This information helps your therapist better understand you better.

Do you have a history of any of the following mental health conditions? Telemedicine is best suited to treat some conditions over others. Telling us about your history will help us find the best care for you. *

Anxiety
OCD (Obsessive-Compulsive Disorder)
Panic disorder
Social anxiety disorder
Depression
PTSD (Posttraumatic Stress Disorder)
Bipolar disorder
Psychosis
Schizophrenia
Eating disorder (bulimia or anorexia)
Suicide attempt
Suicidal thoughts with a plan
Self-harm (e.g. cutting)
Borderline personality disorder
Serotonin syndrome
None apply

Who diagnosed you with anxiety? *

Healthcare provider
Family member
Self-diagnosed

Who diagnosed you with OCD (Obsessive-Compulsive Disorder)? *

Healthcare provider
Family member
Self-diagnosed

Who diagnosed you with panic disorder? *

Healthcare provider
Family member
Self-diagnosed

Who diagnosed you with social anxiety disorder? *

Healthcare provider
Family member
Self-diagnosed

Who diagnosed you with depression? *

Healthcare provider
Family member
Self-diagnosed

Who diagnosed you with PTSD (Post-traumatic stress disorder)? *

Healthcare provider
Family member
Self-diagnosed

Who diagnosed you with Bipolar Disorder? *

Healthcare provider
Family member
Self-diagnosed

Who diagnosed you with Psychosis? *

Healthcare provider
Family member
Self-diagnosed

Who diagnosed you with Schizophrenia? *

Healthcare provider
Family member
Self-diagnosed

Who diagnosed you with eating disorder? (bulimia or anorexia) *

Healthcare provider
Family member
Self-diagnosed

We are currently unable to treat patients with suicidal attempts through telemedicine.

Please contact the Institute of Mental Health at 6389 2200 to book an appointment or email them at imh_appt@imh.com.sg. For more contact information, please visit https://www.imh.com.sg/contact-us/

We are currently unable to treat patients with suicidal thoughts with a plan through telemedicine.

Please contact the Institute of Mental Health at 6389 2200 to book an appointment or email them at imh_appt@imh.com.sg. For more contact information, please visit https://www.imh.com.sg/contact-us/

Who diagnosed you with self-harm? (ie. cutting) *

Healthcare provider
Family member
Self-diagnosed

Who diagnosed you with borderline personality disorder? *

Healthcare provider
Family member
Self-diagnosed

Who diagnosed you with Serotonin syndrome? *

Healthcare provider
Family member
Self-diagnosed

When were you diagnosed for anxiety? *

This information helps your therapist better understand you better.

When were you diagnosed for OCD (Obsessive-Compulsive Disorder)? *

This information helps your therapist better understand you better.

When were you diagnosed for panic disorder? *

This information helps your therapist better understand you better.

When were you diagnosed for social anxiety disorder? *

This information helps your therapist better understand you better.

When were you diagnosed for depression? *

This information helps your therapist better understand you better.

When were you diagnosed for PTSD (Post-traumatic stress disorder)? *

This information helps your therapist better understand you better.

When were you diagnosed for Bipolar Disorder? *

This information helps your therapist better understand you better.

When were you diagnosed for Psychosis? *

This information helps your therapist better understand you better.

When were you diagnosed for Schizophrenia? *

This information helps your therapist better understand you better.

When were you diagnosed for eating disorder? (bulimia or anorexia) *

This information helps your therapist better understand you better.

When were you diagnosed for self-harm? (ie. cutting) *

This information helps your therapist better understand you better.

When were you diagnosed for borderline personality disorder? *

This information helps your therapist better understand you better.

When were you diagnosed for serotonin syndrome? *

This information helps your therapist better understand you better.

Did you treat your anxiety with medications or therapy? If medication, please include name and dosage. *

This information helps your therapist better understand you better.

Did you treat your OCD (Obsessive-Compulsive Disorder) with medications or therapy? If medication, please include name and dosage. *

This information helps your therapist better understand you better.

Did you treat your panic disorder with medications or therapy? If medication, please include name and dosage. *

This information helps your therapist better understand you better.

Did you treat your social anxiety disorder with medications or therapy? If medication, please include name and dosage. *

This information helps your therapist better understand you better.

Did you treat your depression with medications or therapy? If medication, please include name and dosage. *

This information helps your therapist better understand you better.

Did you treat your PTSD (Post-traumatic stress disorder) with medications or therapy? If medication, please include name and dosage. *

This information helps your therapist better understand you better.

Did you treat your Bipolar Disorder with medications or therapy? If medication, please include name and dosage. *

This information helps your therapist better understand you better.

Did you treat your psychosis with medications or therapy? If medication, please include name and dosage. *

This information helps your therapist better understand you better.

Did you treat your schizophrenia with medications or therapy? If medication, please include name and dosage. *

This information helps your therapist better understand you better.

Did you treat your eating disorder (bulimia or anorexia) with medications or therapy? If medication, please include name and dosage. *

This information helps your therapist better understand you better.

Did you treat your eating self-harm (ie. cutting) with medications or therapy? If medication, please include name and dosage. *

This information helps your therapist better understand you better.

Did you treat your borderline personality disorder with medications or therapy? If medication, please include name and dosage. *

This information helps your therapist better understand you better.

Did you treat your serotonin syndrome with medications or therapy? If medication, please include name and dosage. *

This information helps your therapist better understand you better.

Do you have a family history of any of the following? Select all that apply. *

Anxiety
Depression
Suicide
Psychosis
Bipolar disorder
Borderline personality disorder
None apply

Are you currently using any of the following mental health medications? Select all that apply.

Citalopram (Celexa)
Paroxetine (Paxil)
Sertraline (Zoloft)
Fluoxetine (Prozac)
Escitalopram (Lexapro)
Bupropion (Wellbutrin)
Venlafaxine (Effexor)
Duloxetine (Cymbalta)
Mirtazapine (Remeron)
Divalproex (Depakote)
Sleep medication (Trazodone, Ambien, Lunesta etc.)
Anxiety medication (Klonopin, Xanax, Valium, Ativan, Neurontin, Lyrica etc.)
Atypical antipsychotics (Abilify, Seroquel, Risperdal etc.)
Tricyclic Antidepressants (Doxepin, Amitryptiline, Nortriptyline etc.)
MAOI’s (Marplan, Nardil, Parnate etc.)
None apply

For what condition do you use Citalopram (Celexa) *

This information helps your therapist better understand you better.

For what condition do you use Paroxetine (Paxil)? *

This information helps your therapist better understand you better.

For what condition do you use Sertraline (Zoloft)? *

This information helps your therapist better understand you better.

For what condition do you use Fluoxetine (Prozac)? *

This information helps your therapist better understand you better.

For what condition do you use Escitalopram (Lexapro)? *

This information helps your therapist better understand you better.

For what condition do you use Bupropion (Wellbutrin)? *

This information helps your therapist better understand you better.

For what condition do you use Venlafaxine (Effexor)? *

This information helps your therapist better understand you better.

For what condition do you use Duloxetine (Cymbalta)? *

This information helps your therapist better understand you better.

For what condition do you use Mirtazapine (Remeron)? *

This information helps your therapist better understand you better.

For what condition do you use Divalproex (Depakote)? *

This information helps your therapist better understand you better.

For what condition do you use sleep medication? (Trazodone, Ambien, Lunesta etc.) *

This information helps your therapist better understand you better.

For what condition do you use anxiety medication? (Klonopin, Xanax, Valium, Ativan, Neurontin, Lyrica etc.) *

This information helps your therapist better understand you better.

For what condition do you use atypical antipsychotics? (Abilify, Seroquel, Risperdal etc.) *

This information helps your therapist better understand you better.

For what condition do you use Tricyclic Antidepressants? (Doxepin, Amitryptiline, Nortriptyline etc.) *

This information helps your therapist better understand you better.

For what condition do you use MAOI’s? (Marplan, Nardil, Parnate etc.) *

This information helps your therapist better understand you better.

When did you start using Citalopram? (Celexa) *

This information helps your therapist better understand you better.

When did you start using Paroxetine? (Paxil) *

This information helps your therapist better understand you better.

When did you start using Sertraline (Zoloft)? *

This information helps your therapist better understand you better.

When did you start using Fluoxetine? (Prozac) *

This information helps your therapist better understand you better.

When did you start using Escitalopram? (Lexapro) *

This information helps your therapist better understand you better.

When did you start using Bupropion? (Wellbutrin) *

This information helps your therapist better understand you better.

When did you start using Venlafaxine? (Effexor) *

This information helps your therapist better understand you better.

When did you start using Duloxetine? (Cymbalta) *

This information helps your therapist better understand you better.

When did you start using Mirtazapine? (Remeron) *

This information helps your therapist better understand you better.

When did you start using Divalproex (Depakote)? *

This information helps your therapist better understand you better.

When did you start using sleep medication? (Trazodone, Ambien, Lunesta etc.) *

This information helps your therapist better understand you better.

When did you start using anxiety medication (Klonopin, Xanax, Valium, Ativan, Neurontin, Lyrica etc.) *

This information helps your therapist better understand you better.

When did you start using atypical antipsychotics (Abilify, Seroquel, Risperdal etc.) *

This information helps your therapist better understand you better.

When did you start using Tricyclic Antidepressants (Doxepin, Amitryptiline, Nortriptyline etc.) *

This information helps your therapist better understand you better.

When did you start using MAOI’s (Marplan, Nardil, Parnate etc.) *

This information helps your therapist better understand you better.

What dosage of Citalopram (Celexa) are you using? *

This information helps your therapist better understand you better.

What dosage of Paroxetine (Paxil) are you using? *

This information helps your therapist better understand you better.

What dosage of Sertraline (Zoloft) are you using? *

This information helps your therapist better understand you better.

What dosage of Fluoxetine (Prozac) are you using? *

This information helps your therapist better understand you better.

What dosage of Escitalopram (Lexapro) are you using? *

This information helps your therapist better understand you better.

What dosage of Bupropion (Wellbutrin) are you using? *

This information helps your therapist better understand you better.

What dosage of Venlafaxine (Effexor) are you using? *

This information helps your therapist better understand you better.

What dosage of Duloxetine (Cymbalta) are you using? *

This information helps your therapist better understand you better.

What dosage of Mirtazapine (Remeron) are you using? *

This information helps your therapist better understand you better.

What dosage of Divalproex (Depakote) are you using? *

This information helps your therapist better understand you better.

What dosage of sleep medication (Trazodone, Ambien, Lunesta etc.) are you using? *

This information helps your therapist better understand you better.

What dosage of anxiety medication (Klonopin, Xanax, Valium, Ativan, Neurontin, Lyrica etc.) are you using? *

This information helps your therapist better understand you better.

What dosage of anxiety medication atypical antipsychotics (Abilify, Seroquel, Risperdal etc.) are you using? *

This information helps your therapist better understand you better.

What dosage of tricyclic Antidepressants (Doxepin, Amitryptiline, Nortriptyline etc.)are you using? *

This information helps your therapist better understand you better.

What dosage of MAOI’s (Marplan, Nardil, Parnate etc.) are you using? *

This information helps your therapist better understand you better.

Is Citalopram (Celexa) an effective treatment for you? *

Is Paroxetine (Paxil) an effective treatment for you? *

Is Sertraline (Zoloft) an effective treatment for you? *

Is Fluoxetine (Prozac) an effective treatment for you? *

Is Escitalopram (Lexapro) an effective treatment for you? *

Is Bupropion (Wellbutrin) an effective treatment for you? *

Is Venlafaxine (Effexor) an effective treatment for you? *

Is Duloxetine (Cymbalta) an effective treatment for you? *

Is Mirtazapine (Remeron) an effective treatment for you? *

Is Divalproex (Depakote) an effective treatment for you? *

Is sleep medication (Trazodone, Ambien, Lunesta etc.) an effective treatment for you? *

Is anxiety medication (Klonopin, Xanax, Valium, Ativan, Neurontin, Lyrica etc.) an effective treatment for you? *

Is atypical antipsychotics (Abilify, Seroquel, Risperdal etc.) an effective treatment for you? *

Is Tricyclic Antidepressants (Doxepin, Amitryptiline, Nortriptyline etc.) an effective treatment for you? *

Is MAOI’s (Marplan, Nardil, Parnate etc.) an effective treatment for you? *

Have you experienced any side effects from Citalopram (Celexa)? *

Have you experienced any side effects from Paroxetine (Paxil)? *

Have you experienced any side effects from Sertraline (Zoloft)? *

Have you experienced any side effects from Fluoxetine (Prozac)? *

Have you experienced any side effects from Escitalopram (Lexapro)? *

Have you experienced any side effects from Bupropion (Wellbutrin)? *

Have you experienced any side effects from Venlafaxine (Effexor)? *

Have you experienced any side effects from Duloxetine (Cymbalta)? *

Have you experienced any side effects from Mirtazapine (Remeron)? *

Have you experienced any side effects from Divalproex (Depakote)? *

Have you experienced any side effects from sleep medication (Trazodone, Ambien, Lunesta etc.)? *

Have you experienced any side effects from anxiety medication (Klonopin, Xanax, Valium, Ativan, Neurontin, Lyrica etc.)? *

Have you experienced any side effects from atypical antipsychotics (Abilify, Seroquel, Risperdal etc.)? *

Have you experienced any side effects from Tricyclic Antidepressants (Doxepin, Amitryptiline, Nortriptyline etc.)? *

Have you experienced any side effects from MAOI’s (Marplan, Nardil, Parnate etc.)? *

What side effects did you experience? *

This information helps your therapist better understand you better.

Are you currently taking any of the following other medications? *

Anti-seizure medication (eg. Dilantin, Carbamazepine)
Anti-coagulants (eg. Warfarin, Aspirin)
Methadone
Antibiotics (eg. Erythromycin, Z-Pak, Ciprofloxacin)
Antifungals (eg. Ketoconazole)
Cimetidine (eg. Tagamet HB)
Pimozide (eg. Orap)
Beta-blockers (eg. metoprolol, propranolol)
Tamoxefin (Soltamox)
Others
None apply

What is the name and dosage of the anxiety medication you used? *

For what condition did you use this anxiety medication? *

When did you start using and for how long did you use this anxiety medication? *

Was this anxiety medication an effective treatment for you? *

Did you experience any side effects from this anxiety medication? *

What were the side effects that you experienced? *

This information helps your therapist better understand you better.

Now we need to ask a couple common questions about your social history and lifestyle.

Honest answers will help your therapist offer the best care for you, and your responses are kept private and confidential.

Have you ever participated in talk therapy or therapy sessions? *

Religion: *

This information helps your therapist better understand you better.

Race/Ethnicity: *

This information helps your therapist better understand you better.

Highest level of education completed? *

This information helps your therapist better understand you better.

What is your gender? *

Male
Female
Trans male/Trans man
Trans female/Trans woman
Genderqueer/Gender non-conforming
Different identity

We ask this question of all of our patients to ensure that we provide you with safe and effective care. We are inclusive of all identities.

What was your sex assigned at birth? *

Male
Female

Do you smoke or use other tobacco products? This includes smoking, chewing, or vaping. *

How frequently are you using tobacco products? *

How many alcoholic beverages do you drink per week? *

0-1 per week
2-4 per week
5 or more per week

Have you had more than 5 drinks at one time in a row sometime over the past 30 days? *

Are you currently using any of the following recreational drugs? Select all that apply. *

Marijuana, THC, CBD
Ecstasy (MDMA)
Stimulants
Poppers
Cocaine
None apply

Do you live alone? *

Who else lives with you? *

In case of an emergency, is there someone we can contact? *

Please provide their name, their relationship to you, and their phone number. *

How would you describe your physical health? Select the answer that best describes your health. *

Excellent
Very good
Good
Fair
Poor

Do you have or have you ever had any of the following conditions? *

Kidney issues
Thyroid issues
Liver disease
Seizure disorder or epilepsy
History or family history of QT prolongation
Glaucoma or family history of narrow angle glaucoma
Diabetes
High blood pressure
Recent heart attack
Heart condition (e.g. heart failure)
Migraines
Stroke
HIV
Cancer or a history of cancer
Drug abuse
Alcohol abuse
Hyponatremia
History of broken bones
None apply

Do you have any other medical conditions? *

What other medical conditions do you have? *

Have you ever had any surgeries or hospitalizations? *

What surgeries or hospitalizations have you had? *

This information helps your therapist better understand you better.

Are you taking any other prescription medication, over-the-counter medication, supplements or herbal remedies? *

What other prescription medication, over-the-counter medication, supplements or herbal remedies are you taking? Please list the name and dose of each. *

This information helps your therapist better understand you better.

Do you have any allergies to food, dyes, medication, or anything else? *

What allergies do you have? *

Are you a registered sex offender? *

We are currently unable to treat registered sex offenders through telemedicine.

Please contact the Institute of Mental Health at 6389 2200 to book an appointment or email them at imh_appt@imh.com.sg. For more contact information, please visit https://www.imh.com.sg/contact-us/

Would you be more comfortable if your therapist were

Male
Female
No Preference

Is there anything else your provider should know? *

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