Dr. Wasif Rizwan Malik

MBBS · FCPS (Neurosurgery) · Consultant Neurosurgeon & Brain–Spine Surgeon

Faraz Hospital, Dubai Mahal Chowk, Bahawalpur  |  0622885604  |  wasif.malik@gmail.com
Senior Registrar Neurosurgery, Bahawal Victoria Hospital (BVH), Bahawalpur

Psychiatric ProformaFemale / General Mental Health Evaluation

Date: _____ / _____ / _______
Ref No: ________________
Referring Physician: _____________

⚠️ Confidentiality Notice: This form contains sensitive personal health information. To be stored securely. Strict patient privacy applies — access limited to treating team only.
📋 Chief Complaint & History of Presenting Illness
🧠 Mental State Examination (MSE)
Appearance & Behaviour
Appearance:
Behaviour:
Speech:
Mood & Affect
Mood (subjective):
Affect (objective):
Mood VAS:
1
2
3
4
5
6
7
8
9
10
1=very low, 5=neutral, 10=very high/elated
Thought Process & Content
Thought Process:
Thought Content:
Perception
Hallucinations:
Other perceptual:
Cognition
Orientation:
Attention:
Memory:
Abstract thinking:
Insight & Judgement
Insight:
Judgement:
📊 Validated Screening Tools
PHQ-9 – Depression Screen
0=Not at all, 1=Several days, 2=>Half the days, 3=Nearly every day
#Over last 2 weeks…Score
1Little interest or pleasure
2Feeling down / depressed / hopeless
3Sleep problems
4Tired / little energy
5Poor appetite / overeating
6Feeling bad about self
7Trouble concentrating
8Psychomotor change
9Thoughts of self-harm / death
TOTAL SCORE
0–4 Minimal · 5–9 Mild · 10–14 Moderate · 15–19 Mod-Severe · 20–27 Severe
GAD-7 – Anxiety Screen
0=Not at all, 1=Several days, 2=More than half the days, 3=Nearly every day
#Over last 2 weeks…Score
1Feeling nervous / anxious
2Can't stop or control worrying
3Worrying too much about things
4Trouble relaxing
5So restless hard to sit still
6Easily annoyed / irritable
7Feeling afraid something awful
TOTAL SCORE
0–4 Minimal · 5–9 Mild · 10–14 Moderate · 15–21 Severe
EPDS – Edinburgh Postnatal
10-item. Threshold ≥10 (possible PND), ≥13 (probable major depression)
WHO-5 Wellbeing Index
5-item. Score ≤52 suggests low mood. Score ≤28: depression screen.
ISI – Insomnia Severity Index
7-item. ≥15 = clinical insomnia
🌸 Female-Specific Hormonal & Reproductive History
Menstrual History
Reproductive / Obstetric
Thyroid / Hormonal
🚨 Safety Assessment
⚠️ Suicidality / Self-Harm Assessment (Confidential)
⚠️ Domestic Violence / Trauma Screening
📂 Past Psychiatric, Medical History & Medications
✅ Working Diagnosis & Management Plan
Primary Psychiatric Diagnosis (DSM-5 / ICD-11)
Severity
Management Plan
Protocol By: Dr. Wasif Rizwan Malik | MBBS, FCPS Neurosurgery | Faraz Hospital, BVH Bahawalpur PSYCHIATRIC EVALUATION PROFORMA  |  Signature: ____________________