Registration No: Address:

Name:
Age:
Gender:
Educational qualification:
Occupation:
Income:
Marital status:
Patients stays with parents:
Stays with spouse:
Has any siblings, if so, how many:
What is the position of the patient in the family: Eldest, middle or youngest or only child:
Any one in the family is suffering/has suffered from any mental disorder:
Any one in the family is suffering/has suffered from any physical disorders:
Presenting complaints: (This should be recorded as the patient narrates what he is feeling in the
order in which the patient is stating it):
Date of onset of illness (The first attack):
Precipitating factor if any:
Duration of illness:
Intensity of illness (on a scale of 10):
Treatment taken:
Got well at any time in between; duration of such period of wellness:
Was there any precipitating factor at each relapse:
How many relapses:
Any other treatment tried in between:
What was the effect: .

In what ways the illness causes inconvenience?

• Has to take leave from work place / school! college
• Cannot carry on even the routine works
• Has to depend on others for everything
• Want to lie down and take rest
• Don’t want to do anything
• Any other

Interview with family members:

• Their view point in regard to all of the above.
• In what ways the illness causes them inconvenience?