IDENTIFICATION DATA

Name: Mr. XXX

Age: 22 yrs
Sex: Male
I.P. no: 1843
Ward: Male open Ward
Address:
Religion: Hindu
Education:
Occupation:
Income: Rs
Marital history - single
Diagnosis: Alcohol Substance abuse
Informant: Patient and patient’s mother
Reliability: Reliable and adequate

1. CHIEF COMPLAINTS
Onset: Insidious
Precipating factor: Not known
Course of illness: Continues

2. HISTORY OF PRESENT ILLNESS

According To Patient
- He says that his wife suicide at last month.
- So he was so depressed.
According To Sister
- Shows disorganized behavior, irrelevant talking
- Aggressive in nature and beats children.
- Goes out of house and tells vague reasons on asking.
- Sets fire to clothes, poor personal care
- Doesn’t sleep and has decreased appetite.

3. HISTORY OF PAST ILLNESS

There is no past history of illness.

4. FAMILY HISTORY
 KEY:

Male:

Female:

Patient

Father —45 years old studied up to B.Sc a farmer by vocation from a rural background he earns
not more than 4000 per month. He is not suffering from any illness. Maintain good relation with
the client
Mother —he is 38 years old , housewife and Has a good relation with the client.
Siblings – studying, maintains good relations with client.

5. PERSONAL HISTORY
a) Developmental History

• Birth and developmental history

He does not have any information.

• Mother’s condition during pregnancy

No relevant history.

• Type of delivery and feeding

 Normal

• Weaning
Started at 5 month.

• Emotional attitude of parents

Loving and caring

 Physical illnesss during childhood:

No evidence of childhood illness.

 Behavior during childhood

 She does not have any information.

b) School record
Joined school at 06 years. Had many friends. Good relationship between friends.
c) Occupational history
Patient is a not interested in job.
d) Social record
Maintained good relationship between family members and others.
o Attitude towards religion and politics
Believed in Hindu. interested in polictics
o Any antisocial trends.
Interested in alcohol making.

6. SEXUAL AND MARITAL HISTORY

Single.

7. PRE-MORBID PERSONALITY
 Social relationship:
The client has not good relationship with his family members and enjoys
chatting with friends.
 Use of leisure time: spends time with friends.
 General temperament:
Patient is of withdrawn nature, and gets agitated very quickly. Client is very reserved in
nature.

 Intellectual activities:
She is of average intelligence.
 Habits:
He used to have alcohol and nicotin consumption.
 character
a) Atitude to work and responsibility: Not interested
b) Interpersonal relationship: Emotionally controlled.
c) Energy and initiative: Energetic
d) Fantasy life: Not present
e) Habits and addiction: Alchol and nicotin consumption are bad habits.