/ HISTORY TAKING Name? .......e0005 g. Sex: M/F Height. Address .. Locality: Urban/Rural/Semi urban /Hill Type of family: ‘Nuclear/JoinvExtended/Other Educational status: .. Years of formal education Occupation: Full time paid/ Part time paid! Household duties, Housewife/ Unemployed Retired/ student Monthly income: Socioeconomic status: Marital status: Married with one spouse/Married more than once / Unmarried /Divorced/ Separated Source of referral: Self/ Family members/General Practtioners/ Specialists/legal authority/ emergency/other Reason for referral: Informant: Self/Parents/Spouse/Relatives/Friends/Others (to specify) Note on Reliability Adequacy of information: Adequate/Inadequate Chief Complains: 1 Duration Onset ‘Sudden: within 48 hours ‘Acute: Few days to one month (may extend up to 3 months alt ICD-10) Subacute: Within 6 months Gradual: Insidious: Can't exacly pinpoint the onset en aween‘Onset: Sudden/Acute/Subacute/Gradual/Insidious Course: Progressive/static/relapse & recurrence /uncertaln. Precipitating factors: (Temporal relation between stressors and symptom) (to specify below). Elaboration of History of Present Illness: (Add extra sheet if required) Exclusion of negative points: Disability caused by illness: mild/moderate/severe/uncertain Social Occupational Self care Other Burden to care givers: _none/mild/moderate/severe/financial/others (to specif)PAST HISTORY OF MENTAL ILLNESS: | Thelr episodic period > Nature of the illness > How long did it last? Recovery Treatment received vvv Drug Compliance > Functioning PAST HISTORY OF PHYSICAL ILLNESS: > Hypertension/ Diabetes/ Tuberculosis! Epilepsy/ CNS Infection/ Any other significant physical illness > Treatment : completed/ continuing > Name of the drugs with dosage: > Temporal correlation with the psychiatric symptoms: present/absent/uncertain FAMILY HISTORY: a) Types of family: Join/Nuclear/Extended b) Members: (Alive/Death, Age, Occupation Relationship, Qualification, Character, Marital status, Interpersonal relationships, Health status) 1, Father 2, Mother 3. Siblings: (Brother/Sister, Education, Marital status, Relationship, Health) 4) Family Tree: (Incorporate at least 2 generations) Draw a family three ¢) Family History of Psychiatrie: disorders/ Suicide/Alcohol or substance use/ Epilepsy! Abscondance/ Possession/ Mental sub-normality/DementiaPERSONAL HISTORY: ®) Birth history: > TemvPreterm Planned/Unplanned pregnancy > Mode of delivery: Normal vaginal/Forceps/Ventose/Caesarian/Not known > Birth injury > Cried immediately after birth or not Developmental milestones Normal ‘Age Personal and Social Social smile 2-3 months Gross motor Neck holding 3 months Sitting with support ‘S months, Sitting without support 8 months. Crawling 9 months Standing with support U1 months Standing without support 12 months: Walking without support 13 months. Language Cooing 3 months Monosyllabic 6 months | Bisyllabic ‘9 months Simple sentence 24 months * If exact period not known, then may compare with milestones of other normal child. b) Neurotic traits: (Nail biting, Thumb sucking, Bed wetting, Temper tantrum, Head banging, food fad) Play activity Role model How long did ivthese last? (Approx. age) ©) Academic history: > Schooling: At what age did he go to school? > Academic performance > InteresVavoidance/frequent absenteeism > Relation with friends > Truancy 4) Sexual history: > Age of acquiring sexual knowledge - source > Attainment of puberty > Self gratification habit» > » * PremaritaV/Extramaritalsingle/multiple yes/no * Protected/Unprotected Guilt fecting Sexual orientation: Homosexual/Bisexual Abnormal sexual habits ©) Marital History: > > > > > > > > > > > single/multiple ‘With commercial sex workers: ‘Type of marriage: Arranged/ courtship/against wil of selffamily Duration of acquaintance before marriage if any Duration of marriage ‘Children and their health ‘Age of the spouse Character of the spouse Dominant/Adjustable/Submissive/Imitable/suspicious (other specify) ‘Sexual satisfaction Contraceptive measures Marital adjustment: satisfactory/unsatisfactory/uncertain ) Occupational history: Employed/Unemployed/Self-employed Frequent change in occupation - iffso why Satisfaction in Job/Work sufficienvinsufficienvother Earning: >. Relationship with colleague’s/subordinates/superior/friendly/unfriendly 2) Menstrual history: Reaction > > > > wv Menarche (age) Regularity of cycle: Last period Pain during menstruation Psychic changes especially during premenstruum White discharge if any and reaction thereupon h) History of use of alcohol or any other substances: > ‘wvvvy Use: Regular/Occasional How did he start? Type of alcohol: | MFL/Excise/others (10 specify) Recent increase in the amount Mode of administration Last used Others Age at first use: Amount Duration.> Problems associated: Health related/Family related/Financial/Social/Legal > Risk taking behavior > Any medical help > How important is the substance taking habit when compared to the other activities? PREMORBID PERSONALITY: (to emphasize on following polnts and also to enquire) 4) Soctal relations; (relatedness to » Family: attachment/dependence » Friends: Friendly/Warm/Cold/Secretive/Competitive/Jealous > Groups, Societies, Clubs Work and workmates Leader or follower, Organizer, aggressive, submissive, Ambitious, adjustable, independent Relationship with opposite sex: How people describe you? 'b) Intellect (Intellectual activities, Hobbies and Interest, Memory, Judgment) ¢) Mood: (Bright and Cheerful or Despondent/ Worrying or placid/ Strung-up or calm and relaxed/ Optimistic or pessimistic/ Self-depreciative or satisfied/ Mood stable or unstable (with or without any ‘occasion, anxious, mostly unpredictable) 4) Character Attitude to work and responsibility (Welcomes or is worried by responsibility, Makes decisions easily or with difficulty, Haphazard or methodical and meticulous, rigid or le le, cautious, foresightful and given to checking or impulsive and slipshod, Persevering and determined, easily bored and discouraged, Dramatizing, seek for attention or praise)Interpersonal relationships (Self confident or shy and timid, Insensitive or touchy and sensitive to criticism, Trusting or suspicious and jealous, emotionally controlled or quick tempered and irritable, Tactful or outspoken, Monopolize conversation, Quiet and restrained or expressive or demonstrative in speech and gestures, Interest and enthusiasms sustained or not, Tolerant or intolerant of others, Adaptable or inadaptable) ‘Standards in moral, religious, social and health matters > Theist/Atheist > Level of moral values: High/Low > Level of aspiration: High/Low > Realization of mistakes or shortcomings > Perfectionistic and self-critical or complacent and self-approving in relation to own behavior and achievement > Steadfast in face of difficulties or intolerant of frustration > Selfish and egoistic or unselfish and altruistic > Given too much or little concem about own health Energy, Initiative (Energetic or sluggish, Output sustained or fitful, Fatigability: any regular or irregular fluctuations in energy or output) ©) Fantasy life > Frequency and content of day dreaming f) Habits > Eating (fads) > Alcohol consumption > Self-medication with drugs or other medicines > Tobacco consumption> Sleeping > Excretory functions 8) Reaction to Stress: > Unduly Anxious/Frustrated/Shares the problem with others/Indifferent Overall assessment of Premorbid Personality Physical Examination: General Examination: Pallor/icterus/Cyanosis/Clubbing/Koilonychia/Edema/ Pulse = BP= Systemic Examini Respiratory System: Cardiovascular System Gastrointestinal System Central Nervous System: MENTAL STATUS EXAMINATION 1. General appearance and behavior: - Body built: > Personal hygiene and grooming > Eye contact: ‘maintained /not maintained > Facial expression * Byes: Dull/Lusterless/Suspicious/Glistering © Forehead: Forehead wrinkling/Omega sign/Guthrie’s sign/Veraguth sign * Angle of the mouth/Nasolabial fold + Excessive sweating © Rigid/Blunt > Rapport:> Behavior: - Psychomotor Activity . Motor activitics: Agitation/Retardation/Normal * Attitude of the patient: Co-operative, hostile, evasive, threatening, obsequious, interested, seductive, guarded * Body butfer zone or proximity > Catatonie signs: > Abnormal involuntary movements: 2. Mood and Affeet > Subjective: > Objective: > Appropriateness: Congruence: > Range: Reactivity > Stability: > Depth: It is the stage or grading of emotion: Normal/Flat/Blunt/Constricted > Intensity: Normal/Shallow > Rate: Normal/Slow/Fast > Rhythm: Regular/Irregular/Monotonous > Reaction time: Normal/Increased/Decreased > Volume: Low/High/Audible/whispering/Mute > Quantity: Poverty/Pressure of speech > Quality: Nonsensical/ Pedantic/Normal > Spontaneity: Spontaneous /Nonspontancous > Intonation: Presenv/Absent > Articulation defect: > Relevance: 4, Thought: (sample of thought to include) Flow of Thought: Formal thought disorder: Circumstantiality: Tangentiality: Derailment Loosening of association iwwvyba > > > > > > > > Content of thought: > > > > > > > > Word salad. Clang association Punning Over inclusion Flight of ideas Perseveration Verbigeration Thought block Poverty of content Poverty of content Helplessness Hopelessness Worthlessness Tedium vitae Suicidal ideation Possession of Thought: > Obsession and compulsion > Thought alienation + Thought broadcasting = Thought insertion + Thought withdrawal 5, Perceptual Disturbances > > > > > Hallucination Mlusion Depersonalisation/ Déréalisation Déja vu/ Jamais vu Pseudo hallucinations Cognitive Functions : 6. Orientation > Time> Place > Person 7, Attention and Concentration » Serial substraction (100-7) > Spell backward (WORLD) > Vigilance test > DET: 5-6 digits > DBT: 4-5 di 8, Memory > Immediate: S-object recall, DFT, DBT > Recent: Within hours to days/Months > Remote: Personal information 9. General information and intelligence > General Information > Vocabulary /Verbal fluency > Arithmetic > Digit Span 10, Abstract thinking > Proverb test > Similarity test 11, Judgment >> Test judgment: Patents prediction of what he or she would do in imagery situation. > Social judgment: appropriateness of behavior ina social situation eg, sting posture behavior, dress 12. Insight: Degree of awareness and understanding the patient has that he or she is ill Grade Description T Complete derlal of ines i Sight awareness of being sick and needing helo but denying it at same time i Fwareness of being Sick and needing help but Blaming ton others, on external factors, or on medical versus psychological factors v “wareness tha liness is dv to something unknown in patient 7 Siawian hat alien Ti Tals a anaina What Unlarinatn ihre avnavionnoeEmotional awareness of the motives and ji ofthe ——= orherbie motives and feelings within patient and important people in his Provisional Diagnosis: Multiaxial depress ICD10/DSM IVPlan of Management: