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Gender	Gender Male Female
First Interviewer
Seconed Interviewer
Date Of First Interview
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Summary
Diagnosis/Notes
Social	الام ... البنت الوحيدة على ولدين من سنتين حصل لها اغماء مرتين فى الاسبوع لمدة شهر ونصف ورحنا لكذا دكتور ومكنش عندها مشكلة من كام شهر تقريبًا الخد بينمل وبتلخبط فى الكلام ورجليها بتقف وتتشنج ورجليها ببتعوج وبتقع رحنا عند مخ واعصاب وقال معندهاش حاجة 20/2 الماضى كنا فى فرح لسنها وقف وبقت تصرخ جامد لمدة ساعة ونصف وريالة وبرضوا مفيش حاجة سارة 100 شخصية فى بعض ، بتعمل حاجات من وراء الام حاسة انها مظلومة عنها علاقات متعددة بالاولاد ؟؟؟ المستوى الدراسى بدء يقل من 6 ابتدائى بعد ما خرجت من الحمام فى 6 ابتدائى وهى عريانة ومش عارفة تتكلم من 4 العصر لغاية بليل بعدها بشهر دخلت الامتحان والمستوى قل الاعدادية اولى اعدادى كان بيجلها الاغماءات المتكررة (16) مرة وعملنا اشعة مقطعية ورنين وكانت كويسه ثانية اعدادى بدء يحص اعوجاج القدم الاعددية المجموع وحش وخلت خاص سارة .. انا مش مستريحة خالص فى حياتى / امى عصبية وبتتكلم معايا بصوت عالى / مش بتخرجنا خالص / ولا بتجبلى خاحات جديدة / لم بيحصل مشاكل بين ماما وبابا ببقي مضايقة على بابا لانه شايل العم ومش اعد معانا غشان يجبلنا اى حاجو عايزنها امى بتحب اخواتى الصبيان عنى وداينا نصرة اخويا الكبيرة عليه وبتجبلهم اكل ولا نا لا ، بتكلم عليه وعلى اى مشاكل بعملها ادام خلاتى وساعات بتنصرهم عليه / حتى جرتنا تشتكى منى ليها نفسى اخرج مع اصحابى نفسى ابطل عياط حاسة انى قليلة انا بكرة معاملة امى ليه انا بعشق حاجة اسمها بابا /دايما ماما تقلى انتى مش بنتى / مكنتش اتنى تكونى بنتى / ولما اجى احضنها تقلى انتى قرفتينى فى عشتى ا انتى عقدة حياتى ى / قائمة الاعراض اظهرت ارتفاع فى معظم الاعراض الخاصة بالاضطهاد والقلق والاكتئاب والهسترية اظهرت ارتفاع سمات الشخصية البانواوية الاكتئابية وبعض االشخصية الحدية
Allergy
Family History	Family History No Yes
Follow Up

Depressive symptoms	Depressive symptoms Depressed mood Anhedonia Decrease concentration Easy fatigability Death wishes Suicidal ideations/plans/attempts Hopelessness / helplessness Sense of suffocation Significant weight loss Insomnia Psychomotor retardation Psychomotor agitation Excessive guilt
Manic symptoms	Manic symptoms Irritable/elated mood Volubility Flight of ideas Decrease need for sleep Easy distractibility Inflated self-esteem Increase goal directed activities Hyperactivity Involvement in risk activities

Delusions	Delusions General delusions Bizzare Delusion Acting out No acting out Others
Hallucinations	Hallucinations Auditory Non auditory Acting out No acting out Perception illusion Others

Sleep	Sleep Insomnia Interrupted sleep sleepiness Cataplexy Night mares Obstructive apnea/ hypopnea Sleep walking
Appetite	Appetite Decrease appetite Increase appetite Eating non-food substance Repeated regurgitation of food Restriction of eating Recurrent binge eating Recurrent compensatory behavior
Sexual symptoms	Sexual symptoms Decrease desire Increase desire Erectile dysfunction Premature ejaculation Anorgasmia Dyspareunia Paraphilia Gender incongruence

Agitation	Agitation Yes No
Aggression	Aggression Verbal Physical sexual Destruction Homicide
Obsessions/ compulsions	Obsessions/ compulsions Obsessions Compulsions Hoarding Body dysmorphia Skin picking Hair bulling
Suicide	Suicide Death wishes Ideations Plans Attempts current Prior attempts
Anxiety symptoms	Anxiety symptoms Mental symptoms Physical symptoms Ill-defined fear Specific phobias Panic attacks
PTSD Symptoms	PTSD Symptoms Intrusive memories (thoughts- feelings- images- nighmares) Hyperarousal Avoiding dissociation Negative thinking Mood changes
Somatic symptoms	Somatic symptoms Hypochondriasis Conversion Induction of disease or physical symptoms Falsification of physical/psychological symptoms
Dissociative symptoms	Dissociative symptoms Depersonalization/ derealization Others
Neurocognitive symptoms	Neurocognitive symptoms Learning / Memory Attention Language Social cognition Self care House keeping Daily activities Ambutaion?????

Speech	Speech Delay Stuttering Vocal tics Others
Intellectual functions	Intellectual functions Daily activity Social functions Cognitive ?????? Others
Restricted/repetitive behavior Angry/irritable mood	Restricted/repetitive behavior Angry/irritable mood loses temper touchy resentful Others
Argumentative/defiant behavior: Vindictiveness (Aggression)	Argumentative/defiant behavior: Vindictiveness (Aggression) aggressive impulses verbal bullying threatening physical animal People Propities Sixual Stealing Setting fire Others
Enuresis	Enuresis Primary Secondary Others
Encorporesis	Encorporesis Primary Secondary Others
Attention	Attention Attention deficit Forgetfulness Easily distracted Others
Activity	Activity Hyperactivity Hypoactivity Others
Motor	Motor Ticks Delayed motor development Soft motor skills Sleep development Gender identity Others
Personality-ClusterA	Personality-ClusterA Pervasive distrust Detachment from social relationships Odd beliefs / thinking
Personality-ClusterB	Personality-ClusterB violations of rights Impulsivity Unstable relationships Unstable sense of self DSH Dramatization Ego inflation
Personality-ClusterC	Personality-ClusterC Social inhibition Difficulty in everyday decisions without help Details oriented Perfectionism Rigidity
Anxiety & Cluster C
Substance abuse/dependence	Substance abuse/dependence Harmfull use Craving Withdrwal symptoms Unable to control use Others
Impairement of functioning	Impairement of functioning Understanding and communication Getting around Self care Getting along with people Life activities (House hold) Life activities (school /work) Participation in society Others
Severity	Severity 1 2 3 4 5 6 7 8 9 10

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