2. Name starting with first name
Date and place of birth
Sex
Height
Weight
Qualification
Occupation and position/designation
Address
Residence
Office
Phone
Residence: Office:
Mobile:
B.P
PULSE
RESPIRATION
3. Please answer the following for proper assessment
of your physical health
Present history
State your chief complaints and mention about the
following.
When did the complaints start?
Did they start suddenly or insidiously?
Are they increasing in severity or decreasing?
Are they having any pattern, such through out
day and night, only in evenings or mornings, or
alternate day, every week, every fortnight etc?
Are they associated with any other thing such as
food, sleep, any individual, any event etc?
INVESTIGATIONS, DIAGNOSIS,
TREATMENT AND ADVICE
NAME OF THE DOCTOR/S, HOSPITAL AND
PHONE NUMBERS / MOBILE
Vital information
Please describe your posture during
4. Standing
Sitting
Reading
Walking
Sleeping
Any changes in posture
Please state matrimonial status
Married
Unmarried
Divorcee
Widow/widower
Separated
VASAECTOMY
TUBECTOMY
LSCS [caesarian section]
Any other information such as love break
Occupational history
Please write about your
1] Present job
2] Nature of job and working conditions such as
shift duty, kind of work, travelling, targets, dead
lines etc.
3] Income from the job and other sources
4] Past job
5. 5] The motivation behind leaving past job and
taking present job
6] Interpersonal relationship
7] Appraisal by the superiors
8] Occupational satisfaction
9] Any other information about your occupation
such as loans
10] Strike
11] Lay off / VRS
12] Unemployed [For how many years?]
13] Terminated, suspended etc.
Schooling background
Please inform in brief about
1] Performance
2] Changes in performances
3] Problems in motivation and interest in learning
4] Any complaints about the adjustment in school
College Background
Extracurricular activities
About sports activity if any Please mention
Indoor games
Outdoor games
Trekking
Hiking
6. Not interested in sports
Mention about your hobbies.
Music
Arts
Reading,
Painting
Any other
Please give information about the following so as
to complete past history
Were you born naturally or cesarean, forceps etc
was required? Was the delivery conducted at
home or hospital?
Major illness or similar illness in the past
Investigations and treatment
Any major traumatic or pleasant event in the past
such as love breaking or success in interview
respectively
Any other
Family History
A] Please state the following
7. Name of the spouse if applicable and his/her status
Names of father and mother and their status
Names of grand father and grand mother and
their status
Names of children
Names of other relatives of concern
B] Describe the interpersonal relationship in
family according to following points
Relationship of parents
Relationship amongst the family members
Relationship with the neighbor
Past history of the family
A] Please give information about physical history
of the family with respect presence of the
following
Tuberculosis
Cancer
Any other major illness
Major accidents
Deaths
Any other traumatic event
8. B] Please inform about the following so as to
describe psychological history of the family
Sad events
Marriage breaking, dowry death and/or
harassment, Financial loss
Social rejection or isolation, any other traumatic
event,
Happy events
Marriage, get together etc
Please complete this for the assessment of
instinctual status
Please state your habits with respect to quantity,
frequency and duration.
Tea
Coffee
Alcohol
Tobacco
Nail biting
Blinking of eyes
Shrugging shoulders
The causes of addictions
Please describe in brief the exercise you are
involved in with respect to
1] Type: yoga, aerobic, walking, jogging, weight
lifting etc.
2] Intensity
9. 3] Regularity
4] Duration
5] Any other information
6] No exercise
Please inform about your appetite
Is it normal?
Are there any recent changes in appetite?
Have you developed appetite for abnormal
inedible stuff?
Give any other information with respect to
following.
Indigestion
Gases
Belching
Flatus
Please state in details your dietary habits with
respect to following points.
Home food
Outside hotel food
Consumption ice creams and chocolates and such
junk food
Vegetarian
Non-vegetarian
Fruits
10. Vegetables
Sprouted beans
Water intake
Salt intake
Spices and chilies
Pattern of eating
Aerated and/or non-aerated cold drinks
Food grains: Refined or hand pounded and
varieties
Oil and its varieties
Any other
Please describe your bowel habits with respect to
following points
Regular
Irregular
Frequency
Symptoms associated with defecation
Consumption of laxatives and purgatives if yes
which and for how long and how much
Enema
Any other information
Please inform about any difficulty in emptying
urinary bladder and urine output.
Incontinence
Dribbling micturition
Psychological retention
11. Bed-wetting
Please give the information about the following
points in reproductive history
Age of menarche
Age of menopause if applicable
Any symptoms associated with menstrual cycle
Problems if any with respect to pregnancy
/deliveries
Nocturnal emission
Please state the condition of your sleep
Sound
Disturbed
Pattern
Any other
Teeth biting
Snoring
Dreams
Please state if there is any difficulty in speech such
as
Slurred
Staccato
Stammering
Scanning
12. Please state if there is attraction towards opposite
sex, same sex or hatred towards opposite or the
same sex.
Which of the following three you agree with?
A] Sex is good/virtuous/ideal or the only goal of
life.
B] Sex is bad/sin/has to be suppressed.
C] Sex is a part of normal healthy life, humane
sexual aspects have to be understood and
practiced.
Do you have knowledge about reproductive
physiology and sex?
Do you have awareness about sexually transmitted
diseases?
Do you have awareness about family welfare and
contraception?
Do you have satisfaction in the sexual life?
How is your relationship with spouse? Please state
if you are not able to give adequate time to your
spouse or get from him/her.
13. Have you been exposed to sexually transmitted
disease?
Do you have the habit of masturbation
Please state if there are problems with respect to
lactation and breast-feeding and rapport with
children. Can you give adequate time to your
children, parents and/or get it from them.
Please state if you are missing your native place,
culture, family members, other beloved etc.
Please state if or not you do not get opportunity to
move around in the open or go for outing.
Do you like remaining alone?
Do you feel insecure with respect to your life due
to some reason or other?
Please answer the following as honestly as possible
to depict your emotional make up.
HAPPINESS: What is your idea of happiness?
What makes you happy?
SADNESS: Do you feel sad and low at present?
Why? Do you feel like crying more often than
14. previously? Why? Do you get suicidal thoughts?
Why?
RAGE: Do you get violent thoughts? Why?
LOWLINESS: Do you get feeling of dejection?
Why? Do you feel hesitant before starting any
activity? Why? Do you feel that you are inferior to
others? Why? Do you feel shy to talk in a group or
in public meeting? Why?
DESPONDENCY: Have you lost interest in your
day to day activities? Why?
HOPELESS NESS: Do you feel that there is no
charm in life? Why? Do you feel that there is no
hope whatsoever? Why?
CONCERN: Do you feel concern towards the
underprivileged, handicapped, other ailing fellow
beings?
FEAR: Are you afraid of any thing? Of what and
why? Do you always feel that unpleasant things
are going to happen?
GUILT: Do you feel guilty? Of what and why?
15. JEALOUSY: Do you feel jealous about the
others? Why?
INSUFFICIENCY: Do you feel that you do not get
what you deserve at home or in society such as
money, love, respect, fame, pampering etc? Why?
Do you feel that others do not love you? Why?
SUPERIORITY: Do you feel that you are superior
to others? Do you feel proud? Why?
DEPENDENCE: Do you seek help more than
what you give? Why?
Do you blame others for your failure? Why?
DELUSIONS: Do you feel that people are
conspiring against you? Why?
COMMUNICATION: Do you get misunderstood?
If yes, why?
GENEROSITY: Do you give others what the
others expect from you?
GULLIBLITY: Do you get cheated by the others
physically, sexually, emotionally and/or or
financially? How?
16. LONLINESS: Do you feel lonely?
RESTLESSNESS AND ANXIETY: Do you feel
tensed up and find it difficult to sleep? Do you
become irritable due to tension?
Please give information about your behavior with
respect to following points
When do you wake up in morning?
Do you pray in morning?
Do you clean your mouth and teeth regularly?
How? How many times?
Do you take bath regularly? How many times?
Which soap you use?
Do you keep your private parts clean?
Do you keep your clothes clean and tidy?
Do you wash your hands before taking food?
Is there time crunch to reach school, college or
working place?
17. Do you shout at the others or use insulting/abusive
language?
Do you engage yourself in back biting?
Do you indulge in physical violence towards
weaker members of the family?
Do you experience physical violence by others?
Do you indulge in stealing, cheating etc even
against your wish?
Are you involved in any political, religious, social,
charitable activity?
Are you a member of a union? What is your view
about labor movement?
Do you use perfumes?
Do you get gifts? Which?
Do you give gifts? Which?
18. Please inform about your intelligence with regard
to
Concentration
Memory
Attention
Alertness
Analysis
Synthesis
Conceptualization
Innovation
Imagination
Invention
Curiosity
Please answer the following so as to give a picture
of your perspective about life
What are your aims? Why?
What are your views about the healthcare system,
health education and health status?
What do you understand by stress and conceptual
stress?
What are the causes of stress?
19. What are the mechanisms underlying stress?
What are the dimensions of stress?
What is the meaning of support systems?
What is homeostasis? What is social homeostasis?
What is the significance of concepts such as
equality, inequality and harmony?
Do you think that social, political, religious and
cultural picture is bleak? Why?
Do you think that corruption affects you? Why
and how?
Do you think that educational policy is
immaculate and satisfactory?
Do you think that state of children in the world is
fair and satisfactory?
Is the state of elderly and the ailing individuals
satisfactory?
Do you subscribe the policy of reservations for
some sections of the society? If yes, why so and if
no, why so?
20. Have you attended any stress management course
of have consulted any one? What has been your
impression about the same?
What is the meaning of paradigm shift?
What is the difference between stress relaxation
and stress management?
What is the meaning of introspection,
prioritization, assertion, reinforcement, one step at
a time, mission oriented thinking?
STATE YOUR OBSERVATIONS AFTER
STARTING THE TOTAL STRESS
MANAGEMENT [TSM] COURSE WITH
RESPECT TO ABOVE POINTS AND ANY
OTHER INFORMATION
Best Wishes
for your
