Questionare – Wimhans

Questionnaire

Wimhans Hospital

Wisdom Institute Of Mental Health And Neuroscience
Documentation Regarding The Person Requiring Treatment

Questionnaire

Name of the patient

Age

Alcohol, Drug Addiction/Psychiatry Problem

Years your ward having this problem

Name and relationship of the person filling this form

1. Explain briefly about Psychological condition of the patient’s mother during Pregnancy (Depressed, Stress, Worried, If any other specify)

2. Specify the nature of birth of the patient (Natural, Premature baby, Caesarian baby)

3. Describe the patient’s life from childhood until present, give incident to illustrate any special characteristics both positive and negative (Hyperactive, Adamant and Moody)

4. Briefly explain if any of the family members has/had psychiatry problem / alcohol / drug Problem.

5. When did you or your family members identify an abnormal or behavioual change in the
Patient or you found his/her addiction. If so did you take him to the Doctor.

Doctor Name

Prescribed Medicines

6. Give the detailed illustration of the patient’s attitude and behavior prior to addiction to Alcohol, drugs or psychiatry problem.

7. Give the detailed incidents showing the attitudes/behaviours after the onset of addiction/
Psychiatry problem

a. Parents

c. Children

b. Spouse

d. Place of work/job

8. Tell us about any incident past or present which affected or triggered the patient’s Psychological condition / alcohol, drug addiction.

9. In case if the patient is a female describe patient’s health and behavior pattern during Menstrual period.

10. Give detailed information of any past or present already treated for heart problem, diabetic, CKD, Liver problem, OCD, loss of appetite, insomnia, seizures. If yes enclose the details of the clinic where the treatment had been taken with the prescribed medicines.

11. Any emotional disorder past or present from a psychiatrist for depression, mania anxiety, Schizophrenia, manic depressive psychosis, delusion.

12. Explain whether the patient was administered ECT or EEG (give details for the same)

13. Whether the patient had any head injury, if so enclose the treatment details

14. Has the patient in the past threatened or attempted for suicide

15. Has he disturbed or hurt others by words or deeds that is his parents, wife or children

16. How has the patient’s drinking/drug/psychiatry problem affected the family.

Filled by wife/mother/father/husband/children:

Questionnaire

Wimhans Hospital

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