Patan Academy of Health Sciences

School of Nursing & Midwifery, (LNC)

Sanepa, Lalitpur

Format for Mental Health History

Name of student:
Date:
A. Identification of the patient
1. Demography data
 Patient’s name
 Age
 Sex
 Marital status
 Father/spouse
 Educational status
 Occupation
 Religion
 Residential & Official Address/Temporary & Permanent address & contact telephone
number
 Income/socio-economic background

Informants: Information: relevant/not relevant, adequate/not adequate

 Who is giving information about the patient’s illness? (Name, age, sex, education,
occupation)
 Relationship with the patient
 Intimacy with the patient
 Does the informant live with the patient? (length of stay with the patient)
 Duration of relationship with the patient
 Source of referral and reason

2. Inpatient record
 Ward:
 Bed no:
 Date of Admission:
 Inpatient no:
 Diagnosis:
 Name of consultant doctor:

3. Presenting chief complaints

 According to Patient:
 According to informant:
(With duration in chronological order, in patient’s own words & informant’s own words)
4. History of present illness
 Onset (Abrupt/acute/subacute/insidious)
(within 48 hrs/within 1 week/1-2 weeks/within a few weeks)
 Duration (days/week/months/years),
 Course (continuous/episodic/fluctuating/deteriorating/improving/unclear)
 Intensity (same/increasing/decreasing)
 Precipitating factors
 Aggravating, maintaining and or relieving factors, if any.
 Severity and use of medication
 When the patient was last well or asymptomatic
 Any disturbance in the physical functions like sleep appetite, bowel, bladder, body weight,
personal hygiene daily responsibility and sexual functioning should be inquired.
 Suicidal ideation
 Important of negative history should be recorded (e.g. no history of head injury before the
onset of illness).
 Previous treatment in detail

5. Treatment History
 Drugs
 ECT
 Psychotherapy
 Family therapy
 Rehabilitation

6. Past History
A. Past Psychiatric history
B. Past Medical/Surgical history
C. History of previous hospitalization
Reason for hospitalization

7. Family History
Family structure:
 Drawing of a family tree
 Type of family
 Describe the family chart
 Presence/absence of mental illness and major medical illness
 Relationship among them
 Leader of the family
 Current attitude of the family members towards the patient’s illness

8. Personal history
A. Prenatal history
 Any febrile illness, drugs or alcohol use
 Trauma to abdomen
 Physical and psychiatric illness during pregnancy (Particularly in first trimester)
 Was the patient a wanted or unwanted child
 Complication during pregnancy
 Types of delivery: Normal/Abnormal/ Instrumentation
 Place of delivery: Home/Hospital
 Birth cry
 Was the baby normal and breast feed
 Condition of mother during postnatal period

B.Childhood history
 Participation of parents in child’s care
 Age at weaning
 Developmental milestones: Normal/delayed
 Behavioral and emotional problems: Thumb sucking/excessive tantrum/ stuttering, nail
biting, pica, enuresis, nightmare, phobia
 Illness during childhood: CNS infection/epilepsy/neurosis/malnutrition

C. Educational history
 Age at beginning of school
 Relationship with peers and teachers
 Attendance, school phobia, learning abilities, conduct disorder (truancy/stealing)
 Extracurricular activities
 Educational level of patient
 Reason for termination of studies

D. Play history
 Relationship with peers mostly with opposite sex:
 Type of games, with whom and where

E. Puberty History
 Appearance of secondary sexual characteristics
 In males: Nocturnal emission:
Masturbation:
 Anxiety related to pubertal changes
 Emotional problems during adolescence (running away from home/ delinquency / smoking
/drug-taking/any other)

F. Menstrual history in female

 Age of menarche
 Menstruation regular and monthly or not
 Problem during menses
 Date of last menstrual period

G. Obstetric history
 LMP
 Number of children
 Any abnormalities associated with pregnancy, delivery, puerperium
 Termination of pregnancy
 Menopause

H. Occupational history
 Age at starting work
 Jobs held in chronological order:
 Reasons for changes:
 Current job satisfaction: (Including relationship with authorities, colleagues, subordinates)
 Whether job is appropriate to patient’s background
 Note income

I. Sexual and marital history

 Age of marriage
 Relationship with spouse
 Type & duration of marriage
 Interpersonal and sexual relationship
 Details of spouse and children
 Premarital and extramarital relationship

J. Premorbid personality
 Interpersonal relationship: (extrovert/introvert)
 Family and social relationship
 Use of leisure time
 Predominant mood: Optimistic /pessimistic/stable/fluctuating/cheerful
 Usual reaction to stressful events: highly adjustable/anxious
 Attitude towards self and others
 Attitude towards work of responsibility
 Religious beliefs and moral attitudes
 Fantasy (Daydreams-frequency & content)
Habits
 Eating pattern
 Elimination
 Sleep
 Use of drugs, tobacco, alcohol