GAUTAM HOSPITAL AND RESEARCH CENTER
PSYCHOLOGICAL EVALUATION REPORT
(NOT VALID FOR MEDICO-LEGAL PURPOSES)
Reg. No.
Name: Age: year Sex: F S. No.:
Marital Status: Married Edu.: Occ.:
Type of Family: Nuclear Past H/O illness: Absent H/O Family Psychiatric Illness: Absent
H/O Sub. Abuse: Absent Personal History: Absent Add.:
Contact No.: Tests Administered: YMRS
Time Consume: am- pm Date:
PRESENTING COMPLAINTS/CLINICAL FEATURES:
less talk; staring behavior; wandering behavior; Irrelevant talk;
excessive talk; highly religious; Hears Accusatory Remarks; Vision
of Threatening Images; Neglect activities of daily living;
Irrelevant laugh & cry; self muttering; obstinate behavior;
shouting behavior; Irrelevant Thoughts; Confused Thoughts;
Disconnected Thoughts; Disorganized Thoughts;
Nervousness; Feels Highly Active; Lack of social interaction; Poor
Interpersonal Relationship;
Big talk; Have Exaggerated Self – Opinion; Feels Have Unusual
Ability & Powers; Aggressive behavior; Hyper vigilance; Increased
Motor activity; Decreased Motor activity; Suspicious Towards
Family Members; Assaultive Abusive; Verbally Abusive; Feels Life
Is Not Worth Living; Have Suicidal Ideas and Gestures; Made
Suicidal Attempts; Prefers Seclusion; Unnatural movements or
posture; Bizarre appearance; Difficulty Falling Asleep; Broken
Sleep; Restless Sleep; Lack of Morning Freshness; Loss of
Interest; Loss Of Feelings;
Irritability; Worries about Minor Matters; Fearful Anticipation;
Apprehensive Attitude;
Palpitation; Headache; Pain In Body; Pain In Limbs; Stomachache;
Dizziness; Restlessness; Decreased Appetite; Loss of Appetite;
Heavy Feelings in Abdomen; Feels Weak and Fatigued; Sluggish
Limb Movements; Preoccupied With Thoughts about Health;
Occurrence of Fits is there; Hyperactive; Gets easily distracted;
Difficulty keeping attention; Denies being ill at all;
BRIEF HISTORY:
Patient is among – siblings. She got married – years ago and has –
children. According to the attendant, patient’s problem started –
years ago. At that time she took stress about. After that she
started showing symptoms such as decreased sleep and appetite,
. For that she took treatment from – with relief. Now she is
showing all above mentioned presenting complains.
TECHNICAL DETAILS:
Information regarding patient was taken from Her ( ).
REPORT AND ADVICE: