1. IDENTIFICATION DATA - AGE, SEX, EDUCATION, RELIGION, OCCUPATION,

MARITAL STATUS.

2. CHIEF COMPLAINT-PRESENT ILLNESS - C/C

- WHO REFERS ?

- WHEN WAS THE LAST TIME THE PI. FELT WELL ? (ONSET).

3. PAST HISTORY. - PREVIOUS SIMILAR C/O, TX, RESULT OF TX

4. PERSONAL HISTORY - PREMORBID HX - CHILDHOOD, SCHOOLING, SOCIAL LIFE, WORK, MARRIAGE.

- PSYCHOSOCIAL STRESSORS - RELATIONSHIP WITH FAMILY MEMBERS

- ANY MAJOR CHANGES IN LIFE

- WORK PROBLEMS ?

- FINANCIAL PROBLEMS ?

- SEXUAL PROBLEMS ?

- DEATH

- ILLNESSES

- RETIREMENT, ETC.

5. FAMILY HISTORY - SIMILAR PROBLEM IN FAMILY MEMBERS ?

- ANY ILLNESSES OCCURED IN MORE THAN ONE MEMBER OF THE FAMILY ?

- F/H OF MENTAL ILLNESS - SUICIDE

- HOSPITALIZED

- DRINKING PROBLEM

6. MEDICAL HISTORY 1. ILLNESS HX - NEUROLOGICAL S/S

- HEAD INJURY

- MEDICATION TAKING

- USE OF DRUGS & ALCOHOL

- OPERATION