PERSONAL INFORMATION
Name:
Father/Husband’s Name:
Sociodemographic profile-
Age-
Sex-
Education-
Occupation-
Socio economic status-
Religion-
Residence-
Language spoken-
Type of admission-
Proforma
Reliability: Satisfactory / Unsatisfactory
Adequacy: Adequate / Inadequate
Presenting complaints:
HISTORY OF PRESENT ILLNESS
Evolution and sequence of symptoms. Predisposing, Precipitating, Perpetuating
factors (Physical, Pharmacological and Psychosocial), limiting and modifying
factors. Problem (interpersonal, somatic, neither). Patient's view of
responsibility for the problem. Patient's pervasive and persistent mood. Impact
of present illness on patient's attitude (personal, social, professional
(functioning). Role functioning and Biological Functioning (sleep, appetite,
weight, gastrointestinal issues). Activities of Daily living and personal care.
Duration:
Onset of Illness: Abrupt / Acute / Chronic / Not Known.
Course of illness: Continuous / Episodic / Insidious/ Not Known
Progress of illness: Deteriorating / Improving / Static / Fluctuating / Not
Known.
Precipitating Factors:
Perpetuating Factors:
Predisposing Factors:
Brief description-
Negative History:
________________________________________________________________
CONCOMITANT CHANGES IN BIOLOGICAL NEEDS / FUNCTIONS
Appetite: Normal / Reduced / Increased.
Libido: Normal / Mildly Reduced / Markedly Reduced / Enhanced.
Sleep: Normal / Inability to fall asleep / frequent awakening / early morning
insomnia / Total Insomnia / Reversal of Sleep habit / Nightmares / Night
terrors / Somnolence /Hypersomnia / Sleep talking / Sleep walking
Treatment History
PAST MEDICAL/ PSYCHIATRIC HISTORY
Previous episodes, symptoms, duration, probably diagnoses, hospitalizations,
inter-episodic functioning. Deficits (stable, Increasing). Medication (Dosage,
duration, and compliance, response, adverse effects). Reason for poor
compliance, if applicable.
Family History of psychiatric and physical illnesses (upto three
generations)
Family Tree (upto three generations)
FAMILY DETAILS
a) Members living together
b) Earning heads and decision makers -
c) Interpersonal relationships & communication pattern -
d) Attitude of family towards patient's illness
e) Family support system
f) Family burden
g) Expressed emotions/ critical comments:
h) Emotional over involvement
i) Family environment in childhood/ adolescence –
PERSONAL HISTORY
a) Birth and Developmental History:
b) Consanguinity in Parents:
c) Birth Term: Full Term / Premature
d) Birth Type:
e) Birth weight & Birth cry:
f) Milestones: Normal / Delayed / Grossly Delayed.
o Motor
o Language
o Cognitive
o Social
Any significant information:
Childhood Disorders/ Behaviour:
(a) Thumb Sucking
(b)Stammering
(C) Obstinacy
(D) Bed Wetting
(E) Phobias
(F) Temper Tantrums
(g) Night Terrors
(H) Truancy
(I) Food Fads
(J) Nail Biting
(K) Delinquency
Other*
EDUCATIONAL HISTORY
Highest Grade Ccompleted:
Academic Performance:
Peer Relations:
Any Disciplinary Problems:
Participation in co-curricular activities:
Hobbies and Interests:
Remarks-
OCCUPATIONAL HISTORY (Applicable / Not Applicable)
Started working at the age of:
Any change of Jobs: No / Yes* *Give details:
Duration of Present Job:
Has the patient been working in the past 1 year/6 months:
Work Record: Good / Satisfactory /Unsatisfactory*.
MENSTRUAL HISTORY: Applicable / Not Applicable.
(a) Any Amenorrhea: Yes/ No
(b) Age at Menopause: .............. Years/ Not applicable
(c) Related Symptoms (Specify):
HOME ATMOSTPHERE (during childhood & adolescence)
SCHOLASTIC AND EXTRACURRICULAR ACTIVITY-
SEXUAL HISTORY:
Adolescent sexual Activity, Knowledge, attitude towards sex, enquire for any
abuse, practices and deviances
MARITAL HISTORY;
Marital Status: Unmarried/ Married / Separated / Divorced / Widow
Age at marriage……….Years
Parental consent: Yes / No
Details of Spouse:
Age at marriage……….Years
Consanguineous: No / Yes
(a) Education Occupation:
(b) Marital Adjustment: Good / Satisfactory / Unsatisfactory.
(c) Sexual Adjustment: Good / Satisfactory / Unsatisfactory.
(d) Extra-marital Relations: No / Yes*. *Specify:
Family of procreation
PREMORBID PERSONALITY
Social relations
Intellectual activities, Leisure & Habits
Predominant mood
Character-
Attitude towards Self
Attitude to work & responsibility
Interpersonal relationships
Moral Standards, and religious
Fantasy Life:
MENTAL STATUS EXAMINATION
Language of interview:
Use of interpreter:
GENERAL APPEARANCE AND BEHAVIOUR:
General physical appearance: Kempt/ Overtly made up/ Unkempt and untidy/
Sickly/ Perplexed)
Estimate of age: Appropriate to age/ younger than stated age/ older than stated
age
Body build: Pyknic/ Leptosomes/ Athletics/ other
Dress: Appropriate/ Shabby/ Inappropriate
Bodily hygiene: Present/ Partial/ Absent
Touch with surroundings: Present/ Partial/ Absent
Eye contact: Present/ Partial/ Absent
Facial expressions:
Posture:
ATTITUDE TOWARDS EXAMINER: (Cooperative / Attentive / Defensive /
Exhibitionistic /Seductive / Hostile / Playful / Evasive / Guarded /
Uncooperative / Suspicious).
Comment:
Rapport:
MOTOR BEHAVIOUR: (Hyperactive / Aimless / Awkward / Destructive /
Self Injuries / Aggressive/ Silly Smiling/ Tics / Mannerisms / Preoccupied /
Retarded / Waxy flexibility / Odd postures / Rigid / Touching Examiner/
Perseveration / Stereotypes/ Gestures / Grimaces / Restless / Hallucinatory /
Others" Specify:
VOICE AND SPEECH:
Coherence: Coherent / Incoherent.
Productivity: Normal / Overabundant / Scant.
Goal direction: Goal directed / Circumstantial / Tangential.
Intensity: Audible / Excessively loud / Abnormally soft. Pitch: Normal
fluctuations / Monotonous.
Quality: Soft/ Hoarse/ Prosody.
Reaction time: Normal / Delayed.
Speed: Normal / Very slow / Rapid / Pressure of Speech
Ease of speech: Spontaneous / Hesitant / Mute / Slurring / Stuttering
/Whispering / Muttering / Speaks only when questioned.
Relevance: Relevant / Irrelevant / Flight of Ideas.
Manner: Relaxed / excessively formal / Tensed up / inappropriately familiar /
Disinterested.
Deviation: Nil / Rhyming and Punning / Talking past the point / Clang
associations / Stereotypy / Perseveration.
Sample of Talk:
MOOD AND AFFECT:
Subjective:
Objective: Euthymic/ Anxious/ Fearful/ Depressed/ Crying spell/ Irritable/
Enraged/ Euphoric/ Elated/ Cheerful/ La-belle indifference/ Blunt/ Flat)
Intensity of affect: Shallow/ Blunted/ Flat
Depth: Normal/Shallow
Range: Adequate/ Restricted
Mobility/Stability: Stable/ labile/ incontinence
Appropriateness to the situation/ thought – paramimia/ parathymia
Reactivity:
Communicability:
Diurnal variation: worse in morning/ worse in evening/ worse at night
THOUGHT: Document verbatim of speech and when relevant written samples
under the following heads to substantiate inferences.
a) Stream:
Normal
Retarded
Thought blocking/ Perseveration
Accelerated
Flight of ideas/ Prolixity/ Pressured speech
b) Form:
Loosening of association, derailment, neologisms, Clang associations
c) Possession: comment on obsession and thought alienation, experiences for
example, thought insertion, thought withdrawal, thought echo and thought
broadcasting.
(Obsessions: thought/ images/ rumination/ doubts/ impulses/ phobias/ slowness)
d) Content:
Dominant preoccupations including worry, somatic symptoms
Phobias:
(Ideas of reference, worthlessness, helplessness, hopelessness, suicide, death
wishes, guilt, etc. Distinguish between Idea, overvalued idea and delusion.
Describe the delusion as primary, secondary, systematized, unsystematized,
mood congruent, mood incongruent, wherever relevant.)
Sample talk
PERCEPTUAL DISTURBANCES
Sensory deception:
Continuous vs. discontinuous
Control
Diurnal pattern
Objective Vs subjective space,
Modality
Content & response to content
Insight into phenomena
Distinguish between true, pseudo hallucination, imagery, illusion,
autoscopic/others
Sensory distortion: (Comment on the dulled or heightened perception and
change in quality.)
Changes in intensity: Hyperaesthesia/Hyperacusis/Hypoacusis
Changes in quality: Xanthopsia/ Chloropsia / Erythropsia
Changes in spatial form: Micropsia/ Macropsia/ Parropsia/ Meglopsia
SENSORIUM
Orientation:
Attention and Concentration:
Memory: Immediate/ Recent/ Remote
Abstract Thinking
Proverb:
Similarities & Differences:
Assessment: Conceptual / Functional / Concrete.
Intelligence- comprehension, general information, calculations, vocabulary
JUDGEMENT:
(a) Social:
(b) Personal:
(c) Test:
Insight:
1. Complete denial of illness
2. Slight awareness of being sick, but denying at the same time
3. Awareness of being sick but blaming it on external factors
4. Awareness that illness is due to something unknown in the patient.
5. Intellectual insight
6. True emotional insight
Diagnostic Formulation:
Provisional diagnosis with points in favor & Against:
Differential diagnosis with points in favor & against:
Prognosis and management plan:
Reported by:
Consultant note and signature:
