Department of Psychiatry

National Mental Health Programme

District -

I.P.D. Case Record

Registration Number: Date of Registration:

1. SOCIO- DEMOGRAPHIC DETAILS

Name: ..................................................................................... Age: ...................... Sex: Male Female

Domicile: Rural Urban Education: ..................................... Occupation: ..................................

Current Employment: Unemployment Employed Regularly Employed Irregularly

Marital Status: Unmarried Married Widow/Widower

Separated Divorced

Religion: Hindu Muslim Sikh

Christian Other

Referring Agency: Self/ Family Ex. Patient Court/Police NGO

Informants: Name- ........................................................... Relationship with Patient- ...........................................

Reliability- ......................................................
1. Onset:
2. Precipitants:
3. Duration:
4. Rx response:
Previous psychiatric Hx/Counselling/Suicide attempts/Violence:

Previous diagnoses:

Medications/Tx:

Psychiatric Dx/Visits/Counseling/Suicide attempts:

Substance use:

Suicide:

5. MEDICAL HX 6. SYSTEMS REVIEW

CNS:
Previous illnesses & treatment:

H & N:

CVS:

Head injury (+/- LOC) and workup/imaging: RESP:

GI:
Medications:

GU:

Alcohol use:
MSK:

-counter/illicit med/drugs) DERM:

 7. PERSONAL HX

Place of birth:

As a child: (family structure, parents’ occupations, relationship with parents, siblings, friends, abuse)

As a teen: (friends, relationships, school, activities, sex, trouble, relationship with parents)

8. MSE 9. FOLSTEIN MMSE

Appearance: Orientation: /10
· Gait
Time: Year
· Posture
· Clothes Season
· Grooming Month
Behaviour: Date
· Mannerisms
· Gesture Day
· Psychomotor activity Place: Floor
· Expression
· Eye Contact Building
· Ability to Follow Commands/ requests City
· Compulsions
Province
Attitude:
(Cooperative, Hostile, Open, Secretive, Evasive, Suspicious, Country
Apathetic, Easily Distracted, Focused, Defensive)

Level of Consciousness: Immediate recall: /3

(Vigilant, Alert, Drowsy, Lethargic, Stuporous, Asleep, Comatose, Attention: /5
Confused, Fluctuating)
Delay recall: /3
Orientation:
· Name Naming: /2
· Place Repetition: /1
· Time
3- stage command: /3
Speech:
 Quality: Reading: /1

Talkative, Spontaneous, Expansive, Paucity, Poverty Copying: /1

 Rate:


Total: /30

 Fluency & Rhythm:

Slurred, Clear, Hesitant, Aphasic
Mood:
· Subjective
· Objective

Affect:
(Labile, Range, Quality Appropriateness, Congruent)

Thought:
· Form
· Content

Perception:
· Hallucination, Illusion

Insight:
(Absent/ Present)
· Grade I
· Grade II
· Grade III
· Grade IV

Judgement:

11. PLAN

Investigations:

Treatment:
 Biological:

 Psychological:
12.