Online Assessment – Undoyourstress

Psychiatric consultation with Dr. Kishore Chandiramani

Dr. Chandiramani offers psychiatric consultations, including tele-psychiatry sessions, to clients suffering from a wide range of psychological problems.

Keeping up with the advancement in technology the initial part of this consultation can be completed by the clients themselves online. This facilitates a capture of comprehensive account of clients’ difficulties in their own words. This online consultation is for 15 years and above only. Please ring +44-1782-768656 to enquire about the consultation fee.

The disorders commonly treated are anxiety, depression, phobias, OCD, alcohol and drug problems, eating disorders, relationship difficulties, manic depressive disorders, psychotic illnesses such as schizophrenia, personality difficulties including borderline personality disorder, avoidant personality disorder, dysthymic disorders, etc, and work related stress. We also prescribe medication such as antidepressants, anti-anxiety, antipsychotics, mood stabilisers, etc.

First of all, I want to reassure you that we treat this information as highly confidential and it will not be disclosed to any individual or organization without your consent.
In the normal course we share this information with your GPs, but if you don’t want this to happen please let us know and in certain circumstance, when a medication is not being prescribed, it should be possible for us to keep it fully confidential

Please read and provide your consent as per the GDPR declaration that allows us to keep this confidential information on our records for as long as necessary from your point of view as per the government regulations. You can withdraw this consent at any time and ask for these records to be transferred to another provider or be sent to you.

Personal Information
Present and Past Medical Conditions
Physical Health and Medications
Family History
Personal History

Personal Information

Name

Date of Birth

Home Address

Contact Number

Next of Kin

Name

Relationship

E-mail

Contact Number

GP Details

GP Surgery Name

Address

Contact Number

Other Details

Source of Referral ( how did you come to know about us?)

Do you have any allergies? If yes, please mention.

Source of Funding
Self Paying Insurance

Your Health Insurance Details

Name of Insurance Provider

Membership Number

Authorization Number

Physical Health

Have you suffered from any of the following:
Epilepsy Hypertension Comprised heart functioning

Please tell us the names of physical illnesses that you have suffered from over the years (eg hypertension, asthma, diabetes, weight problem)

Current Medication

For psychiatric illnesses

For physical illnesses the main ones

Family History

Father - age, occupation, how would you describe his personality and your relationship with him, and if deceased - the cause of his death and age when died.

Mother- age, occupation, how would you describe her personality and your relationship with her, and if deceased - the cause of her death and age when died.

Are your parents together - if divorced or separated - how old were you when they got separated.

How many siblings have you got - number of brothers and sisters, your relationship with them.

Is there any family history of psychiatric problems within your immediate family - parents, siblngs and children - please describe briefly and if they have sought treatment?

Diagnosis/treatment received if known. Please specify.

Is there any family history of psychiatric problems with your uncles, aunts, grandparents and cousins.
Yes No

Diagnosis/treatment received if known. Please specify.