Present Complains (Write in your own words)
Past History (Give in sequential order with treatment taken)
History of injury/accident
About your Family & Hereditary
Father
Mother
Occupation
Occupation
Disease (if any)
Disease (if any)
Brother's & Sister's
No. of Brothers
No. of Sisters
Disease (if any)
Disease (if any)
Any major disease in Maternal/Paternal side
Married at age of
About your Spouse
Occupation
Disease (if any)
Children
No. of Son
Disease (if any)
No. of Daughter
Disease (if any)
You as individual stages of life
Your Birth
Select One
Normal
Premature
Caesarean
Your childhood (education & major events)
Adolescence / Puberty
Adulthood
Present life
Different changes in nature of occupation
Your financial status at different stage of life
History of any failure /
disappointments, grief, reverse of fortune, loss of money, ambitions, fright
(specify)
History of
vaccinations and any health problem related to Vaccination
Your mind, intellect, will, emotion & consciousness
Your own
observation about mind
Your memory
Select One
Active
Normal
Forgetful
Weak
Observation of other
about your mind
If forgetfulness then specify for what
Your anger
Select One
Easily angered
Trifles
Violent
Mild
Suppressed
Silent Grief
If other please
specify
Your reaction in
anger (eg. throwing things, striking yourself , leaving meals, weeping,
suicidal)
Your fear of what (eg:
ghosts, snakes, high places, dark, alone etc.)
Your anxiety (of
what) and since when
Weeping and effect of
consolation
Select One
Easily
Trifles
Cannot weep
Religious affection
Select One
Normal
Too much occupied
Want of religious feeling
Spending of money
Select One
Avarice
Generous
Extravagant
Normal
Liking for Music and type
Select One
More
Indifferent
Hate Music
Normal
Liking for Nature
Select One
More
Too much occupied
Want of religious feeling
Habits
Behavior
(eg. Biting nails)
Narcotics
Select One
Yes
No
Alcohol
Select One
Yes
No
Excess
Sometimes
Tobacco
Select One
Yes
No
Excess
Sometimes
Colors you like most
Colors you don't like
Social likings
Select One
Like Alone
Better in Alone
Like company of few
Like large crowd
Delusion (if any)
Consolation
Select One
Likes
Dislikes
Irritated
No effect
Nature
Select One
Aggressive
Submissive
Withdraw
Dominative
Dictatorial
Thoughts
Select One
Burned in thoughts
Absorbed
Absent minded
Talking
Select One
Too much talkative
Silent
Talking in sleep
Normal
Fastidious
(particular about )
Select One
Appearance about
Dress about
Time about
If others specify
Physical
Vertigo
Pain
Head
Hair
Dandruff / Lice
Eye (during sleep)
Select One
Closed
Open
Partially Open
Ear
Face
Nose
Mouth (during sleep)
Select One
Closed
Open
Partially Open
Salivation
Growth
Teeth
Pain
Caries
Throat
External Throat
Stomach
Appetite
Food liking
Dislike
Abdomen
Pain
Digestion
Flatulence
Stool Color
Rectum
Pain
Growth
Chest
Heart
Back (region)
Extremities
Sleep
Position
Covers
Select One
Likes
Dislikes
Must
Dream
Select One
Casual
Repetition
Perspiration
Parts of body
Staining
Odor
Bath
Select One
Like
Dislike
Bath with
Select One
Cold water
Warm water
Air
Select One
Open
Likes
Dislikes
Feels better
Worse
Closed
Draft
Weather (feels
better in)
Weather (feels worse in)
Season
Liking
Dislike
Sex (Male)
Desire
Select One
Normal
Increased
Decreased
Any abnormality
Sex (Female)
Menses Interval
Duration
Color
Pain or associated trouble
Other discharges
Other abnormalities
Medical treatment taken
Select One
Yes
No
Diagnosis made earlier
Select One
Yes
No
Diet routine & food taken
Besides these questions you can answer following questions in detail
or any other thing which you want to share with us.
1. General Symptoms
Q. 1 -
At what time in the 24 hours do you feel worst?
Q. 2 - In which season do you feel less well?
Q. 3 - How do you stand the cold, hot, dry, and wet weather?
Q. 4 - How does fog affect you?
Q. 5 - What do you feel when exposed to the sun?
Q. 6 - How does change of weather affect you?
Q. 7 - What about snow?
Q. 8 - What kind of climate is objectionable to you, and where would you choose to
spend your vacation?
Q. 9 - How do you feel before, during and after a storm?
Q. 10 - What are you reactions to north wind, south wind, to the wind in general?
Q. 11 - What about draughts of air and changes of temperature?
Q. 12 - What about warmth in general, warmth of the bed, of the room, of the stove?
Q. 13 - How do you react to extremes of temperature?
Q. 14 - What difference do you make in your clothing in winter?
Q. 15 - What about taking colds in winter and in other seasons?
Q. 16 - How do you keep your window at night?
Q. 17 - What position do you like best sitting, standing, lying?
Q. 18 - How do you feel standing a while, or kneeling in church? What sports do you
engage in? What about riding in cars or sailing? How do you feel before, during,
and after meals?
Q. 19 - What about your appetite, how do you feel if you go without a meal?
Q. 20 - What quantity and what do you drink? What about thirst?
Q. 21 - What are the foods that make you sick, and why?
Q. 22 - Like : sweets, salty things, sour, greasy food, eggs, meat, pork, bread, butter,
vegetables, cabbages, onions, fruits?
Q. 23 - What about wine, beer, coffee, tea, milk, vinegar?
Q. 24 - How much do you smoke in a day, and how do you feel after smoking?
Q. 25 -
Are the drugs to
which you are very sensitive or which make you sick?
Q. 25 - What are the vaccinations you have had, and the results from them?
Q. 27 - What about cold or warm baths, sea baths?
Q. 28 - How do you feel at the seaside, or on high mountains?
Q. 29 - How do collars, belts, and tight clothing affect you?
Q. 30 - How long are your wounds in healing, how long in bleeding?
Q. 31 -
2. Mental symptoms
Q. 32 - What are the greatest grief's that you have gone through in your life?
Q. 33 - What are the greatest joys you have had in life?
Q. 34 - At what time in the 24 hours do you feel blue, depressed, sad, and pessimistic?
Q. 35 - How do you stand worries?
Q. 36 - On what occasions do you weep?
Q. 37 - What effect does consolation have on you?
Q. 38 - On what occasions do you feel despair?
Q. 39 - In what circumstances have you ever felt jealous?
Q. 40 - When and on what occasions do you feel frightened or anxious?
Like, some people are afraid of the night, of darkness, to be alone, of robbers,
of certain animals, of death, of certain diseases, of ghosts, to lose their
reason, of noises at night, of poverty, of storm, of water.
Q. 41 - How do you feel in a room full of people, at church, at a lecture?
Q. 42 - Do you go red or white when you are angry, and how do you feel afterwards?
Q. 43 -
How do you stand
waiting?
Q. 44 - How rapidly do you walk, eat, talk, write?
Q. 45 - What have been the complaints or effects following chagrin, grief, disappointed
love, vexation, mortification, indignation, bad news, fright?
In time of depression, how do you look at death?
Q. 46 - Tell me about over-consciousness and over-scrupulousness, about trifles; some
people do not care about too many details and too much order.
3. Food cravings and aversions
Of course, all these questions have been already asked in the beginning of the
questionnaire, but by asking you again, you are able, by doing some
cross-questioning, to determine if they have been answered well the first time
or not.
Q. 47 - What is the kind of food for which you have a marked craving or aversion, or
what are those that make you sick or you cannot eat?
Q. 48 - What about pastry and sweets?
Q. 49 - What about sour or spiced food?
Q. 50 - What about rich or greasy food?
Q. 51 - How much salt to you need for your taste?
Q. 52 - What about thirst and what do you drink? Coffee wine, beer, etc.
4. Sleep
Q. 53 - In which position do you sleep, and since when that position? Where do you put
your arms, and how do you like to have your head?
Q. 54 - What are you doing during sleep?
Like some people speak, laugh, shriek, weep, are restless, are afraid, grind
their teeth, have their mouth or their eyes open.
Q. 55 -
At what time do
you wake up, or when are you sleepy? What makes you restless or sleepy?
Q. 56 - What about dreams?
Questionnaire
For
Depression
