Adult Case History

Adult Case History Form

1. Basic Information

Name

Age

Email address

Mobile Number

Basic complaint in detail

Since when?

How did it start?

Any preceding events before the complaint began? (Physical / mental)

Any change in work or lifestyle?

Any other complaints?

Past history of all the other previous illnesses?

Family history of ailments? (Parents, brother, sister, and grandparents)

2. Personal History:

How is your appetite?

What happens when you are hungry for long?

What are you likings or cravings in food?

Similarly, what are you dislikes or aversions in food?

Any food which causes problems?

How is your thirst of water?

Bowels / Stools:

Do you have any tendency for constipation or loose motions?

Are your bowels fine?

Sweat or perspiration:

Do you sweat when you exert or otherwise?

Area where you sweat the most:

Does your sweat leave any stains on your clothes?

Does your sweat have any odor or smell?

Urine - Is your urination normal?

Do you have any of the following habits: (Tobacco / Smoking / Alcohol) ?

Only for female patients – Menstrual cycle:

Is your cycle regular?

At what interval?

Is it painful?

Any symptoms before/during/after menses?

History of pregnancy / abortions / miscarriages

Sleep:

How is your sleep?

How long do you usually sleep for?

Position while sleeping?

Dreams which you see often in sleep?

Thermally:

How does your body react to heat or cold?

Can your tolerate heat more or cold more?

How do you feel in the sun?

3. Mind (Please answer freely, frankly and completely. Please do not hold anything back, be open and forthright. Take help if you find difficulty in answering a question or consult us if you don’t understand a question)

Describe your basic nature

Describe your family structure – Who all are present in the family and your relation with parents, in-laws, brothers, sisters, spouse and children

How is your married life?

Emotionally how are you – expressive or unexpressive? Whom would you confide in or express your feelings to?

Temperamentally how are you? Do you get angry easily? How would you express it?

Do you get anxious? (eg: during exam, facing teachers, projects, pending work, public speaking)

Any physical symptoms when you are anxious?

Are you impatient or hurried? About what?

Are you friendly or reserved?

Do you prefer being in company or alone?

Do you remember hurts caused by others for long? How do they affect you? How do you express?

Are you organized about keeping your things or planning your day?

How punctual are you?

How is your confidence level generally? On a scale of 1 to 10, how do you rate your confidence and why?

How is your decision making? Do you take a long time to make decisions? Do you ask people for opinion before making a decision?

Any type of jealousy or suspicion or possessiveness in your nature? If yes, about what?

Describe your work life. Progress in work life and satisfaction, relations with colleagues / subordinates and what they say about you?

How ambitious are you?

How was your childhood? Describe your nature in childhood.

What are your strengths and weaknesses?

In your opinion, what aspects of your mind or nature is not agreeable to you? Inspite of being aware, are you unable to change them?

What has caused sadness in your life?

What are the most happy or joyous moments in your life?

Are you worried or unhappy about any personal, domestic, social or any other situation? (Please describe if any)

Is there any incident in your life that has permanently hurt or damaged you? If yes, kindly explain about it?

Do you have any regrets in life?

What are the activities / hobbies you like? Are you passionate about anything? Similarly do you have any specific dislikes?

Are you fearful of anything? (eg: darkness / being alone / disease / future / high places / animals / water / etc.)