Where is the trouble / what exactly does you feel or have there / What are the factors that makes this trouble better or worse ? / Onset of trouble
Any particular feeling or symptoms appear before during and after sexual intercourse ?
Do you have increase desire or decreased desire for sex ?
FOR MEN
Any difficulty in erection ? Wanted erection ? Unwanted erection ? Weak erection / Failing erection - Describe ? Any other trouble in sex ?
FOR WOMEN
Menses: How are the periods - Regular / irregular and at what age did it start ?
Was any trouble then ?
Mention interval between periods.No. of days of flow. Menstrual flow:
is there any change now in Quality / Colour / Smell or Consistency ?
Are stains difficult to wash ?Yes No .
Do you noticed any variation in quality and quantity of flow during menses ? How & When ?
Do you suffer in any way before, during or after menses if so describe:
What symptoms did you suffer during menopause ?
Do you feel the internal parts coming down ?
Is there any white discharge ?
Nature / Colour / Consistency / Smell, When & under what circumstances it more or less, has the discharge any relation to menses ?
Do you pass any gas from Vagina ?Yes No .
Any trouble with Breasts ?
Are you doubtful or suspicious ? of what ?
What are you jealous about ? of whom ? , From what symptoms do you suffer when jealous ?
In which matters are you impatient ? Hurried ?
How long do you remember hurts came to you by others ? Offended easily ?
How much revengeful are you ?
What are you proud of ?
Does your pride get easily hurt ? (Egotism)
Depressed / Brooding etc. ?
Do you ever become suicidal ?
Yes No
When ?
If so in what manner do you contemplate to end your life ?
Even then are you afraid of dying ?
Yes No
When are you cheerful ?
Are you sexual minded ?
Any unwanted thoughts any time ? What are they ?
Have you any imaginary sensations or fears ?
Do you hear voices as that you are called or anything else in this line keeps on occurring in your mind unduly ?
Yes No
How is your memory ?
For what is poor ? e.g. names, places, faces, what you have read, etc
Do you weep easily ?
Yes No
What makes you weep ?
How do you feel after weeping ?
How do you feel if someone offers sympathy and consolation ?
Are you easily irritated ?
Yes No
What makes you angry ?
What bodily symptoms do you develop when angry ? , e.g. trembling, sweating etc.
Do you like company ? or like to remain alone ?
How seriously are you affected by disorder and uncleanness in your surroundings ?
Yes No
What are the greatest griefs that you have gone through in your life ?
What are the greatest joys that you have had in life ?
What activities you deeply like ?
Are there any matters which you deeply dislike ?
In your opinion, which aspects of mind and moods are not agreeable to you. In spite of your awareness and maturity, are unable to change this aspect ?
GIve a clear cut pircure of your situation in life and your relationship with each of your family members , friends and associates in work.
How does the future look to you?