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I remain sad for most of the time in a dayMy thoughts keep on RacingI am worrying a lot in trivial mattersI am unable to enjoy previously pleasurable activitiesI feel hopeless, helpless, worthlessI don't feel relaxedI am having sleep pattern disturbanceI feel guiltyI am not having any interest in activitiesI am having Increased libidoI hear voices talking to me when I am aloneI am not able to concentrate on the work at handI feel fresh even if I sleep very little in the nightI feel people around me are trying to harm meMy appetite has reduced a lotI feel excessively energeticI am having racing heart, sweating, tremors, and stiffness in my bodyI feel that I might die out of a heart attackI am getting irritable easilyI feel easily fatiguedRecently I am crying to myself more frequentlyI have decreased desire to have sexual activityI am talking and planning a lotI have difficulty in talking to new people and adjusting to new situationsI try to eat less as I feel that I am becoming fatI am getting repeated thoughts of contamination and doubtsI get urges to pull my hair and pick my skinI wash my hands again and again. I check things repeatedlyI feel I don't want to live in this worldI get repeated unwanted sexual thoughts and images in my mindI feel my face and facial structures are not symmetricalI feel like committing suicideOther

For Children, kindly fill accordingly

My child doesn't make eye contactMy child is not able to speak as per his/her peer groupNot able to sit at one place, constantly moving around, climbing, jumpingNot able to walkCreates trouble in school and with friendsPlays alone, doesn't mix with friendsPoor social and emotional reciprocity with family membersRepetitive & restrictive behaviors like: flapping of hand, toe walkingDifficulty in studying particular subjects such as Math and EnglishOther

Has anyone in your family been diagnosed with or treated for:

Bipolar disorderDepressionAnxietyAngerSuicideSchizophreniaPost-traumatic stressAlcohol abuseOther

Have you ever tried the following:

CocaineTobacco related productsHeroin / Brown sugarLSD or HallucinogensMarijuana / Bhang / GanjaTranquilizer/sleeping pillsAlcoholEcstasyOther

Do you have any of the following medical conditions?

DiabetesHypertensionHypothyroidismObesityPCOD/PCOS (Females)Seizures/FitsHigh-grade fever with neck stiffnessHead injury with loss of consciousnessPast history of any surgeries