In noting down mental symptoms,mention only those of which you are quite sure.This form is not exhaustive of every case of chronic illness,but will serve as a primary source of understanding your case.
- Name of the patient:..............................................
- Marital status:
- Present and Past occupation:
- Educational Qualification:
- Your complaints;
- What is the work you like the best?
- what is your place like? Hilly,plain,dry,marshy,malarial or associated with any unhealthy environment?
- Is your house well ventilated or located in the open?
- Any previous or present habit of drinking,smoking,or taking any drugs?Any previous history of injury with details?Do you take tea,coffea?,if so how much a day?
- Family History:
-Any history of Diabetes,Hypertension,Asthma,piles,phthisis,neuralgia,neurasthenia,epilepsy,or insanity in the family either on the maternal or paternal side?
-what about brothers and sisters?
15.Any past medical history:
-Any STD to wife/husband/parents?
-any history of taking medicine for any other disease?
16.Any eruptions on the skin,any tumour or wart on any part of the body ?
if cure ,how and when cured?
-Any discharge from skin disease?
-Is it thin,thick,watery,bland,excoriating,sticky,...etc...?
-give its colour ,quality ,smell etc.
17.Was any operation performed on you?If yes where,what for and with what result?
-Did you suffer from typhoid,measles,malaria or any similar disease?If so what was the treatment taken?
-Have you been vaccinated? If so ,how many times?
18.Please give details of present attack as much as you can regarding its onset and course.How long has the patient has been suffering from each attack?Mention aggravation and amelioration of each symptom by day or night ,by exposure or exercise ,by lying down ,sitting up or walking ,or by bathing, by perspiration, by constipation,or diarrhoea ..etc....
19.What all treatment did you undergo for your present ailment?Give details whether allopathic,homoeopathic ,naturopathic ..etc...with names of medicine used and result.
20.What in your opinion was the exciting cause of the first and subsequent attacks,viz domestic worry,financial loss,fear,anger,over-work,night keeping,loss of semen,working in the sun,run-down health,injury,shock,disappointment,convalescence from any diseases?
21.Are you thin or fat and plumpy?Emaciated or stout?Any part less developed than other?Any history of delay in learning to walk ,talk, and dentition.
-When you are in company ,do you by nature ,assume leadership or take a position of less importance?
22.Is the patient chilly or warm blooded?
-Like heat or cold?
-Likes open air?
-Like to sleep in closed windows ,or prefer to lie with doors and windows open?
-Fond of bathing in cold or hot water?
23.Any special craving or dislikes for egg,salt,sugar,meat,alcohol,bitter taste ...etc...
24.Exactly at what times of the day or night does the disease or any particular complaint increase , or decrease and how? Does the disease aggravate by lying on any particular side?Which side is preferred to lie on?
25.Is there any relation of troubles with day or night ,summer,winter,or rainy season,new moon ,or full moon;or with suppression ,or cure of any eruption or disease?How was it suppressed?Any external ointment used?
26.Sleep sound or disturbed,refreshing or not?Sleepless ,from what time to what time?Any aggravation or amelioration during or after sleep ?Any dream of cat,snake,robbers,fire,dead people,daily work,floating in the air,...etc...?Do you put your hands above your head while sleeping or feet out of bed?
27.Feels chilly and feverish before or during the attacks?Is the patient restless then?Care for dry warm application and massage over the limbs?Thirsty and ask for small quantities of water at short intervals,or large quantity at a time?Wants to be covered or uncovered?
28.Does the attack occur at fixed intervals or does it alternate with neuralgia or any other complaints?
In the case of women ,give details of menses,early or late,regular ,irregular,duration ,colour of flow.quantity,clotted or thin, pain if any, where,when,how ameliorated? How does the menses affect the patient's troubles in general? Give details about deliveries,any abortions?Are the children healthy?
29.Against the various parts and functions of the body, mentioned below,state all the abnormalities observed,if any about each,and give details of pain,discharges ..etc...if any with their modalities.
A)HEAD: Heat or burning on vertex ;perspiration on front or back?Itching of scalp?Dandruff?Falling of hair?
B)MOUTH:Bad odour,salivation,taste?Gums swollen:painful?Teeth carious,coated with tartar:pyorrhoea:any grinding of teeth at night?
Throat: Any pain,right sided or left.?pharyngitis?tonsillitis?chronic enlargement of tonsils with frequent attacks of inflammation.Tonsils removed by operation or not?Uvula elongated?Cracks fissures on lips?
Is thirstless? Tongue coating or mark on tongue? thin or flabby ?moist or dry?Any ulcer ,its nature?
C)EYES: Lachrymation with itching or any particularity noted?
D)Nose: Stoppage of nose,nostril?Watering of nose,itching of nostrils and on nose.
E)EAR: Any discharge,thin ,or thick? State colour and odour of discharge.
F)LUNGS: Cough dry or moist,stringy ....etc...
G)HEART: Any palpitation,aggravation from motion or amelioration from it?
H)CHEST: Did you suffer from any disease of chest ?
I)ABDOMEN: Any distention of abdomen ?any eructation ? Does passing of flatus relieve the patient?
Stomach: Appetite increased or decreased?
J) SWEAT: In what part is most marked? Is the attack worse or better with perspiration?Any peculiarity regarding sweat?
K) URINE: Any bad odour,sediment of what colour and consistency?
L) STOOL: Colour, odour, foul or not? Any ineffectual urging to stool? Is the bowel constipated or loose?
M)Hands and Feet: Any burning ?Sweat, if any?
N) ANUS: Is there any pain or discharge?Any fissure or eruption;any history of piles and whether of bleeding nature ? How was it cured? Any external ointment used ?
a)Mild or angry and irritable temper:Quarrelsome,fault finding and obstinate,suspicious,of others ,jealous?
b)Is very talkative or silent ,absent minded,cheerful,gloomy or timid?
c)Neat and clean,or of dirty habits?
d)Desires to be in company or keeps aloof?
e)Any fear of death,or suicidal tendency,Disgusted with life from frequent attacks,from pain or from imaginary causes ?
f)Memory weak or active ,Gradual loss of memory?
g)Weeping mood and involuntary sighing : Cries with reprimanted or gets more angry:?
h) Cries for sympathy?
i)Keeps busy,wants to do every thing in a hurry or slowly.or in a normal manner,very active or dull and backward mentally?
j) Want of concentration? Inferiority Complex?
k)Any other mental symptoms ,whether rare and peculiar or otherwise.Please note that mental symptoms very often take a prominent place in the selection of appropriate treatment.