Client Intake Form

## Client Intake Form **Date of Intake:** 1 November 2024 **Client Information:** * **Full Name:** Sarah Elizabeth Jenkins * **Date of Birth:** 15 March 1988 * **Age:** 36 years * **Gender:** Female * **Address:** 12 Elm Street, Anytown, AB1 2CD * **Phone Number:** 07700 900321 * **Email Address:** sarah.jenkins@example.com * **Preferred Language:** English * **Marital Status:** Married * **Occupation:** Teacher **Emergency Contact Information:** * **Name:** David Jenkins * **Relationship:** Husband * **Phone Number:** 07700 900322 **Medical History:** * **Current Medications:** Sertraline 50mg daily, Folic Acid 400mcg daily * **Allergies:** Penicillin (rash), Latex (skin irritation) * **Past Medical History:** Mild asthma (childhood, well-controlled), Seasonal allergies, History of anxiety (managed) * **Surgical History:** Appendectomy (2005) * **Family Medical History:** Maternal grandmother had type 2 diabetes. Paternal grandfather had hypertension. * **Immunisation Status:** Up to date with all routine vaccinations (Tetanus, Diphtheria, Pertussis, MMR, Varicella, Influenza - most recent October 2024). **Presenting Complaint/Reason for Visit:** * **Reason:** "I've been feeling more tired than usual and experiencing some headaches over the past few weeks. Also concerned about recurrent indigestion." (Patient's direct quote) * **Duration:** Approximately 3 weeks for fatigue and headaches, 2 months for indigestion. * **Severity:** Fatigue rated 6/10, headaches 5/10 (pulsating, frontal), indigestion 4/10 (burning sensation after meals). * **Aggravating Factors:** Fatigue worse in the mornings. Headaches worse with stress. Indigestion worse after fatty foods. * **Alleviating Factors:** Rest helps fatigue slightly. Paracetamol provides temporary relief for headaches. Over-the-counter antacids help indigestion. * **Associated Symptoms:** Occasional dizziness with fatigue. No fever, nausea, vomiting, or weight changes reported. **Social History:** * **Smoking Status:** Non-smoker * **Alcohol Consumption:** Occasional social drinking (2-3 units per week) * **Drug Use:** Denies recreational drug use * **Diet:** Generally balanced, but admits to occasional unhealthy food choices due to busy schedule. * **Exercise:** Walks 30 minutes, 3-4 times per week. * **Living Situation:** Lives with husband and two young children in a house. * **Stressors:** High workload at school, managing young children, recent financial concerns. **Psychological History:** * **Previous Mental Health Diagnoses:** Generalised Anxiety Disorder (diagnosed 2018) * **Therapy History:** Attended CBT sessions in 2019, found it helpful. * **Current Mood:** Reports feeling "a bit down" lately, but denies suicidal ideation or significant anhedonia. * **Sleep Patterns:** Difficulty falling asleep, often wakes up during the night. Feels unrested. **Review of Systems (Brief):** * **General:** Fatigue, occasional dizziness. * **HEENT:** Headaches. * **Cardiovascular:** No chest pain, palpitations. * **Respiratory:** No cough, shortness of breath. * **Gastrointestinal:** Indigestion, no change in bowel habits. * **Musculoskeletal:** No joint pain, muscle aches. * **Neurological:** No numbness, tingling, weakness. * **Endocrine:** No significant weight changes, heat/cold intolerance. * **Dermatological:** No new rashes, skin changes. * **Genitourinary:** No dysuria, frequency. **Provisional Diagnosis/Impression:** 1. Fatigue, multifactorial (stress, sleep disturbance). 2. Tension headaches. 3. Gastroesophageal Reflux Disease (GERD) symptoms. 4. Anxiety, mild exacerbation. **Plan:** 1. **Investigations:** Full blood count, CRP, Thyroid function tests, HbA1c, Ferritin. Refer for H. pylori breath test if indigestion persists. 2. **Medications:** Continue current medications. Recommend trial of omeprazole 20mg daily for indigestion. Review effectiveness in 2 weeks. 3. **Lifestyle Advice:** Emphasise sleep hygiene education, stress management techniques (e.g., mindfulness). Dietary advice for indigestion (avoiding trigger foods). 4. **Referrals:** Consider referral for counselling if anxiety symptoms worsen. 5. **Follow-up:** Schedule review in 2-3 weeks to discuss investigation results and symptom response. **Clinician Signature:** Dr. Evelyn Reed