PERSONAL HISTORY
Name: _______________________________________________________________
Address: _____________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Mobile: Email:
Education: Language:
Occupation:
If Married:
-1-
FAMILY HISTORY
Parents Name: 1.
2.
Siblings Name: 1.
2.
Childhood History:
Psychosexual History:
1. Source of teenage sexual knowledge:
2. Love affairs:
-2-
MEDICAL HISTORY
-3-
3. DSM or ICD 10 criteria met
c. Cause of termination
2. Description of Problem
Hunger/diet:
More/less/proportionate
Sleep:
Time of sleeping:
Quality of sleep: normal/disturbed
Problems with sleep: dreams/snoring/not getting sleep/early morning
awakening/getting sleep for few hours/getting up in midnight
Addiction:
Nature:
-4-
Routine:
Interests/hobbies:
Conclusion
Signature
Goals:
-5-
-6-