Mental Health Assessment | Nesorra Uganda

Welcome

Patient Info

Complaints

Screening

History

Report

Welcome to Your Assessment

This confidential assessment helps our team understand your needs so we can provide the best support.

I am filling this form as a:

Patient

I am seeking help for myself

Guardian

I am filling this on behalf of someone

Clinician

I am a healthcare professional

Your information is private and confidential. This is a screening tool, not a diagnosis. All data stays in your browser — nothing is sent to a server.

Patient Information

Please provide basic details about the patient.

Full Name *

Age (years) *

Gender *

Phone Number *

Next of Kin Name *

Next of Kin Contact *

Presenting Complaints

Describe the patient's main concern and any additional complaints.

Main Complaint *

Anxiety

Depression

Sleep Problems

Anger Issues

Trauma / PTSD

Substance Use

Difficulty Focusing

Mood Swings

Hallucinations

Self-Harm / Suicidal Thoughts

Eating Problems

Stress

Additional Complaints

History of Present Illness *

Medical History

Help us understand your medical background for a more complete picture.

Previous Mental Health Treatment

Have you received mental health treatment before?

Yes No

If yes, please describe

Current Medications

Are you currently taking any medication?

Yes No

If yes, list medications

Medical Conditions

Do you have any chronic medical conditions?

Yes No

If yes, please specify

Family History

Is there a history of mental illness in your family?

Yes No Not sure

If yes, please describe

Mental Status Examination

Document your clinical observations from the mental status examination.

Appearance & Behaviour

Speech

Mood

Affect

Thought Process

Perception

Cognition

Insight & Judgment

Assessment Report

A summary of your assessment will be generated here.

Your full assessment summary — including patient details, complaints, screening results, and medical history — will appear here once the assessment is complete.