CASE TAKING PROFORMA Serial No: -A) Patients Biodata: Name: Age: ..

. Sex: M/F Martial Status: Single/Married/Divorced/Widowed Residence: Urban/Rural Occupation: Socioeconomic Status: High/Middle/Low B) Presenting Complaints: C) History of the present Illness: (Detailed history of present illness with respect to cause and circumstances, duration, mode of onset, location with extension, sensations, modalities and concomitants, if any) D) History of the previous Illnesses: Past Medical H/o patient as per the check list given at the end. E) Family History: In his own, paternal and maternal families as per the check list at the end. F) Personal Details: APPEARANCE: Lean/Obese/Emaciated/Average/Thin/Short/Tall/Stooped/Undernourished WEIGHT: (Increasing/Decreasing/Stationary) APPETITE/TASTE/THIRST: AVERSIONS, DESIRES & EFFECTS OF FOOD: STOOL AND URINE: PERSPIRATION: MENSTRUAL FUNCTION: Menarche: Late/Early L. M. P. Date: __--__--____

Menses: Cycle and Duration with concomitants: Menopause and associated complaints: Leucorrhoea: PREGNANCY AND OBSTETRIC HISTORY: G P A: Mode of deliveries: Mental State during and after Pregnancy Illness and Medication during Pregnancy: H/o oral contraceptives used SEXUAL FUNCTION: Desire/Aversion/Performance and associated complaints. PAEDIATRIC HISTORY: Birth: Normal /Abnormal Birth Wt.: Mother's health: Neo-natal problems: Milestones: Problems: Physical Development / Mental Development Speech: Retarded/Lisping/Stammer/Slow/Rapid Feeding: Breast/Top/Bottle/Solids Observation: Activity: Hyper/Dull/Restless/Destructive/Quiet. Emotional: Anger/Fears/Attachments/Shyness/Change/Responsibility Intellectual: Performance at School and in Extra-curricular activities Hobbies Obedience Socialization Behavioural Problems: Aggressive(Beats, Bites)/Breathholding/Clinging/Contrary/Cruel/Criminal/Dirty/Fastidious/Headbanging/Obs essive/Homesick/Hurry/Stealing/Nailbiting/Obstinate/Rocking/Tantrums/ Tics/ Thumb sucking/ Truant/Weepy SLEEP & DREAMS: Type of sleep: Light/Catnaps/Deep/Un-refreshing/Poor/Siesta Disturbed Due To:

Anger/Anxiety/Work stress/ Dreams/Fears/Lovesick/Thoughts Position during sleep Any change in sleeping pattern Concomitants: Enuresis/Gestures/Grinding/Moaning/Nightmare/Perspiration/Salivation/ Snoring/Starting/Talking/Walking Dreams and their nature: REACTIONS: [Physical factors: (Effects, Ailments from, Agg. And Amel.)] Air: Cold/Open/Fan/Drafts/A.C./Closed room Weather: Clear/Dry/Foggy/Storm/Cloudy/Humid/Cold/Damp/warm/Seashore Seasons: Summer/Spring/Monsoon/Winter/Autumn Wet, getting: General/Local Covers: Covering/Uncovering, Bath Motion Time Position/Posture Coition Meditation Music/Noise/T.V. Light/Lightening/Moonlight Odors/Pain/Color/Dark/Touch/Pressure/Rubbing Sun exposure/Temperature/Thunderstorms/Moon phases Exertion: Physical / Mental Thermal state: Hot/Chilly/Ambithermal Anything else. G) Emotional State: LOVE/ ANGER/ SADNESS/ FEAR/ ANXIETY/HATE/ GUILT/ ENVY / JEALOUSY / SUSPICION AND OTHERS H) Intellectual State: PERCEPTION/THINKING/MEMORY/DECISION/CONFIDENCE/CONSCIOU SNESS/WORK/PERFORMANCE AND OTHERS I) Life situations and circumstances: Self: Major areas of concern and worries: Past:/Present

Major fears Habits and Hobbies Family Patients position in family Spouse Dependents Relationship with wife and children Relationship with parents and siblings Marital Relationship Environment at home Work Environment at work Relationship with Juniors/Seniors/colleagues Job satisfaction Society Relationship with friends and relatives J) Body Language: Gait: Gestures: Postures: Facial expressions: Eye Contact Voice and speech: K) Physical Examination General: Temp. Jaundice Mouth B.P. Cyanosis Tongue Pulse Ear Lymph nodes Oedema Nose Sinuses Anemia Throat Skin: Complexion & Texture, Discoloration, Eruptions, Growths Nails: Brittle, Clubbing, Colour, Deformed, Ingrown, Infection Hair: Growth, Baldness, Colour, Dandruff, Dry, Loss, Tangled L) SYSTEMIC EXAMINATION: RESPIRATORY CVS PER ABDOMEN CNS

MUSCULO-SKELETAL Comments if any: Questionnaire used to elicit the symptoms of the patients:
Patients and the attendants were given ample time to explain about the problem, without interrupting them in haste, yet as and where needed the following type of questions were used; 1. What are the factors that make you worse? 2. What are the factors which make you comfortable? 3. What are the concerns in your life those are bothering you much? 4. In what type of environment you like to be? 5. How will you describe yourself i.e. your nature, behavior, temperament, likings, disliking etc? 6. What fears do you have? 7. How do you react to different situations? 8. What gives you the pleasure most? 9. What makes you angry or anxious? 10. Apart from your business/profession what other activities you like. 11. Which was the worst event of your life? 12. Which were the happiest moments of your life?

Checklist for Past and Family History:

Anaemia Asthma Diabetes Cancer T.B./Pleurisy Injuries / # Bleeding Tendency Chicken-pox/ Measles Heart diseases Resp. diseases Hypo/Hyper - tension Syphilis / Gonorrhoea

Rheumatism /O.A. R.A. / S.L.E Leprosy Musculo-skeletal Jaundice Skin Diseases Paralysis / Polio/Stroke Poisoning / Pollution

Malaria / Typhoid Epilepsy / Fits Mumps / Rickets Stones / Renal diseases

Cholera /G.E. /Ulc. colitis

Mental retardation/Suppressions

Diarrhoea/Dysentery Neurosis / Psychosis Vaccination Exposure : x-ray / radiation Warts / Growths Whooping cough Anything else Otorrhoea / Otitis Worms

Checklist of some Probable Causes

Emotionally disturbing experiences in childhood. Prolonged insecurity. Feeling of unloved / unwanted during childhood. Preference of brother / sister. Death of family member / friend. Disappointment in a love affair. Career disappointment. Unfavourable work situation. Domestic quarrels between parents / spouse / siblings. Separation from parents / spouse. Loss of social position. Disappointment in close relationships Work stresses. Retirement from work. Strict upbringing during childhood. Major personal injury. Monetary losses. Unemployment. Change in Job / Residence. Any other.

Checklist of some Important Observations that can indicate Anxiety Disorders

Hyperactivity of Hands. Fine Tremor of hands. Profuse and cold perspiration Palms and Forehead. Increased Pulse rate. Rapid and short breathing. Facial expression. Biting nails. Tenseness of facial muscles. Hands held in a fist. Crossed Arms. Shoulders Bent forward. Crossed legs. Shoulders bent forward. Head thrust forward. Sitting bent forward. Clenched Jaw. Restlessness of limbs. Avoids Eye Contact. Chafed and reddened Hands. Patchy hair loss.