Appointment – The Mind Cushion

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First Name *

Last Name *

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Gender *

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Female

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Current Duration

Total Duration

Mode of Onset

Course Of Illness

Progress of Illness

Predisposing factors

Precipitating factors

Perpetuating factors

History of Present Illness

Past Psychiatric or Medical History

Treatment History

Type of Family

Details of Family Members

Any consanguineous relationships

Family History of Psychiatric Illness/Major Medical Illness

Family History of Alcohol/Drug dependence

Family History of Suicide

Current Home circumstances

Socio Economic Status

Leader of the family(Nominal and Functional)

current attitudes of family members towards the patient’s illness

communication patterns in the family

Expressed Emotion

Family Boundary

cultural and religious values

Emotional Support System

Economical Support system

Instrumental support system

Home environment at the time of Conception

Type of Delivery

Patient was a planned child/unplanned child

Drug or Alcohol Use during Pregnancy

Place of Birth

any perinatal complications

birth cry

Any birth defect/complications/abnormality

Primary Caretaker

Weaning age

History suggestive of maternal deprivation

Achievement of Developmental milestone

Age and Ease of toilet training

Any neurotic traits

Starting age of going to school/beginning of education

Type of School

Relationship with peers

Relationship with teachers

Any learning difficulty

Attendance

Age of Completing education

Highest qualification degree

Age of puberty/menarche (in females)

Length of menstrual Cycle

Regularity of Cycle

Duration of Menses

Any abnormality

Last menstrual cycle

Termination of pregnancy (if any)

Age of starting Job

Current Job

History of Jobs in chronological order

reasons for changes

job satisfaction

relationships with authorities, peers and subordinates;

present income

Any abnormality in Occupation

Age of getting married

Time duration of Marriage

Number of Children

Any premarital/extramarital sexual relationships

Marriage happened with Client’s consent

Marriage happened with Family Consent

Type of Marriage and time known before marriage

Number of Mariages

Any Divorce (if yes, details)

interpersonal and sexual relations

sexual satisfaction

mode and frequency of sexual intercourse

psychosexual dysfunction (if any)

Psychosexual History

Premorbid Personality

General Appearance

Touch with surroundings

Eye contact with Examiner

Rapport was

Attitude towards examiner

Motor Activity

Voice and Speech

Reaction time

Production of Speech

Mood and Affect

Volition

Hallucination

Modality

Projection

Types

2nd person/3rd person Hallucinations

Stream

Possession

Content

Content Details

Form

Attention and Concentration

Immediate Memory

Recent Memory

Remote Memory

Orientation

Time

Day

Date

Month

Year

Place

Person

Comprehension Q&A

General Info Q&A

Vocabulary Q&A

Arithmetic Calculation

Abstract Thinking

Conceptual Level

Concrete Level

Functional Level

Proverbs (Similarities & Differences)

Personal Judgement

Social Judgement

Test Judgement

Insight Level

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