HOLISTIC HEALTH EXAMINATION ESSENTIAL FOR TOTAL STRESS MANAGEMENT Dr. Shriniwas Kashalikar
Name starting with first name Date and place of birth Sex Height Weight Qualification Occupation and position/designation Address Residence
Office
Phone Residence: Mobile: B.P PULSE RESPIRATION
Office:
Please answer the following for proper assessment of your physical health Present history State your chief complaints and mention about the following. When did the complaints start? Did they start suddenly or insidiously? Are they increasing in severity or decreasing? Are they having any pattern, such through out day and night, only in evenings or mornings, or alternate day, every week, every fortnight etc? Are they associated with any other thing such as food, sleep, any individual, any event etc? INVESTIGATIONS, DIAGNOSIS, TREATMENT AND ADVICE NAME OF THE DOCTOR/S, HOSPITAL AND PHONE NUMBERS / MOBILE
Vital information Please describe your posture during
Standing Sitting Reading Walking Sleeping Any changes in posture Please state matrimonial status Married Unmarried Divorcee Widow/widower Separated VASAECTOMY TUBECTOMY LSCS [caesarian section] Any other information such as love break Occupational history Please write about your 1] Present job 2] Nature of job and working conditions such as shift duty, kind of work, travelling, targets, dead lines etc. 3] Income from the job and other sources 4] Past job
5] The motivation behind leaving past job and taking present job 6] Interpersonal relationship 7] Appraisal by the superiors 8] Occupational satisfaction 9] Any other information about your occupation such as loans 10] Strike 11] Lay off / VRS 12] Unemployed [For how many years?] 13] Terminated, suspended etc. Schooling background Please inform in brief about 1] Performance 2] Changes in performances 3] Problems in motivation and interest in learning 4] Any complaints about the adjustment in school College Background Extracurricular activities About sports activity if any Please mention Indoor games Outdoor games Trekking Hiking
Not interested in sports Mention about your hobbies. Music Arts Reading, Painting Any other Please give information about the following so as to complete past history Were you born naturally or cesarean, forceps etc was required? Was the delivery conducted at home or hospital? Major illness or similar illness in the past Investigations and treatment Any major traumatic or pleasant event in the past such as love breaking or success in interview respectively Any other Family History A] Please state the following
Name of the spouse if applicable and his/her status Names of father and mother and their status Names of grand father and grand mother and their status Names of children Names of other relatives of concern B] Describe the interpersonal relationship in family according to following points Relationship of parents Relationship amongst the family members Relationship with the neighbor Past history of the family A] Please give information about physical history of the family with respect presence of the following Tuberculosis Cancer Any other major illness Major accidents Deaths Any other traumatic event
B] Please inform about the following so as to describe psychological history of the family Sad events Marriage breaking, dowry death and/or harassment, Financial loss Social rejection or isolation, any other traumatic event, Happy events Marriage, get together etc Please complete this for the assessment of instinctual status Please state your habits with respect to quantity, frequency and duration. Tea Coffee Alcohol Tobacco Nail biting Blinking of eyes Shrugging shoulders The causes of addictions Please describe in brief the exercise you are involved in with respect to 1] Type: yoga, aerobic, walking, jogging, weight lifting etc. 2] Intensity
3] Regularity 4] Duration 5] Any other information 6] No exercise Please inform about your appetite Is it normal? Are there any recent changes in appetite? Have you developed appetite for abnormal inedible stuff? Give any other information with respect to following. Indigestion Gases Belching Flatus Please state in details your dietary habits with respect to following points. Home food Outside hotel food Consumption ice creams and chocolates and such junk food Vegetarian Non-vegetarian Fruits
Vegetables Sprouted beans Water intake Salt intake Spices and chilies Pattern of eating Aerated and/or non-aerated cold drinks Food grains: Refined or hand pounded and varieties Oil and its varieties Any other Please describe your bowel habits with respect to following points Regular Irregular Frequency Symptoms associated with defecation Consumption of laxatives and purgatives if yes which and for how long and how much Enema Any other information Please inform about any difficulty in emptying urinary bladder and urine output. Incontinence Dribbling micturition Psychological retention
Bed-wetting Please give the information about the following points in reproductive history Age of menarche Age of menopause if applicable Any symptoms associated with menstrual cycle Problems if any with respect to pregnancy /deliveries Nocturnal emission Please state the condition of your sleep Sound Disturbed Pattern Any other Teeth biting Snoring Dreams Please state if there is any difficulty in speech such as Slurred Staccato Stammering Scanning
Please state if there is attraction towards opposite sex, same sex or hatred towards opposite or the same sex. Which of the following three you agree with? A] Sex is good/virtuous/ideal or the only goal of life. B] Sex is bad/sin/has to be suppressed. C] Sex is a part of normal healthy life, humane sexual aspects have to be understood and practiced. Do you have knowledge about reproductive physiology and sex? Do you have awareness about sexually transmitted diseases? Do you have awareness about family welfare and contraception? Do you have satisfaction in the sexual life? How is your relationship with spouse? Please state if you are not able to give adequate time to your spouse or get from him/her.
Have you been exposed to sexually transmitted disease? Do you have the habit of masturbation Please state if there are problems with respect to lactation and breast-feeding and rapport with children. Can you give adequate time to your children, parents and/or get it from them. Please state if you are missing your native place, culture, family members, other beloved etc. Please state if or not you do not get opportunity to move around in the open or go for outing. Do you like remaining alone? Do you feel insecure with respect to your life due to some reason or other? Please answer the following as honestly as possible to depict your emotional make up. HAPPINESS: What is your idea of happiness? What makes you happy? SADNESS: Do you feel sad and low at present? Why? Do you feel like crying more often than
previously? Why? Do you get suicidal thoughts? Why? RAGE: Do you get violent thoughts? Why? LOWLINESS: Do you get feeling of dejection? Why? Do you feel hesitant before starting any activity? Why? Do you feel that you are inferior to others? Why? Do you feel shy to talk in a group or in public meeting? Why? DESPONDENCY: Have you lost interest in your day to day activities? Why? HOPELESS NESS: Do you feel that there is no charm in life? Why? Do you feel that there is no hope whatsoever? Why? CONCERN: Do you feel concern towards the underprivileged, handicapped, other ailing fellow beings? FEAR: Are you afraid of any thing? Of what and why? Do you always feel that unpleasant things are going to happen? GUILT: Do you feel guilty? Of what and why?
JEALOUSY: Do you feel jealous about the others? Why? INSUFFICIENCY: Do you feel that you do not get what you deserve at home or in society such as money, love, respect, fame, pampering etc? Why? Do you feel that others do not love you? Why? SUPERIORITY: Do you feel that you are superior to others? Do you feel proud? Why? DEPENDENCE: Do you seek help more than what you give? Why? Do you blame others for your failure? Why? DELUSIONS: Do you feel that people are conspiring against you? Why? COMMUNICATION: Do you get misunderstood? If yes, why? GENEROSITY: Do you give others what the others expect from you? GULLIBLITY: Do you get cheated by the others physically, sexually, emotionally and/or or financially? How?
LONLINESS: Do you feel lonely? RESTLESSNESS AND ANXIETY: Do you feel tensed up and find it difficult to sleep? Do you become irritable due to tension? Please give information about your behavior with respect to following points When do you wake up in morning? Do you pray in morning? Do you clean your mouth and teeth regularly? How? How many times? Do you take bath regularly? How many times? Which soap you use? Do you keep your private parts clean? Do you keep your clothes clean and tidy? Do you wash your hands before taking food? Is there time crunch to reach school, college or working place?
Do you shout at the others or use insulting/abusive language? Do you engage yourself in back biting? Do you indulge in physical violence towards weaker members of the family? Do you experience physical violence by others? Do you indulge in stealing, cheating etc even against your wish? Are you involved in any political, religious, social, charitable activity? Are you a member of a union? What is your view about labor movement? Do you use perfumes? Do you get gifts? Which? Do you give gifts? Which?
Please inform about your intelligence with regard to Concentration Memory Attention Alertness Analysis Synthesis Conceptualization Innovation Imagination Invention Curiosity Please answer the following so as to give a picture of your perspective about life What are your aims? Why? What are your views about the healthcare system, health education and health status? What do you understand by stress and conceptual stress? What are the causes of stress?
What are the mechanisms underlying stress? What are the dimensions of stress? What is the meaning of support systems? What is homeostasis? What is social homeostasis? What is the significance of concepts such as equality, inequality and harmony? Do you think that social, political, religious and cultural picture is bleak? Why? Do you think that corruption affects you? Why and how? Do you think that educational policy is immaculate and satisfactory? Do you think that state of children in the world is fair and satisfactory? Is the state of elderly and the ailing individuals satisfactory? Do you subscribe the policy of reservations for some sections of the society? If yes, why so and if no, why so?
Have you attended any stress management course of have consulted any one? What has been your impression about the same? What is the meaning of paradigm shift? What is the difference between stress relaxation and stress management? What is the meaning of introspection, prioritization, assertion, reinforcement, one step at a time, mission oriented thinking? STATE YOUR OBSERVATIONS AFTER STARTING THE TOTAL STRESS MANAGEMENT [TSM] COURSE WITH RESPECT TO ABOVE POINTS AND ANY OTHER INFORMATION
Best Wishes for your
Total Stress Management i.e Holistic Health i.e. Global Welfare i.e. Complete Blossoming i.e. superliving! Dr. Shriniwas Kashalikar