HISTORY TAKING

IDENTIFICATION
• Name:
• Age:
• Sex:
• Marital Status:
• Educational Status
• Occupation:
• Religion:
• Caste:
• Residence:
Present address:
Permanent address:
• Source of referral:
• Informant (name, age, relationship, intimacy and length of acquaintance with the
patient)
Reliability of information:
Adequacy of information:
PRESENTING COMPLAINTS: (with duration)
Patients:
Informants:
HISTORY OF PRESENT ILLNESS:
• Duration
• Onset
• Course of illness : continuous or episodic or continuous with exacerbations
• Progression of severity
• Precipitating factor
 • Description of presenting complaints in detail.
• Relevant positive and negative points.
• Biological symptoms : comparison past and present :sleep, appetite, loss of weight,
libido
• Personal care, work performance, personality changes.
• Treatment history and its effect on course and severity of illness.
PAST HISTORY
• Psychiatric
• Relevant Medical
• Relevant Surgical
FAMILY HISTORY
 Family of origin
 Describe with a family chart.
 Presence or absence of –
• mental illness, t/t
• alcohol or drug abuse
• suicide, unnatural death, disappearance
• medical problems like DM, Thyroid dysfunctions, Neurodevelopmental problems
 Relationship, communication pattern among them
 Attitudes, beliefs regarding illness, choice of treatment
 Personality characteristics, Subsyndromal symptoms

PERSONAL HISTORY
• Antenatal, natal
• Events after birth: crying, breathing, cyanosis, icterus, high temperature, convulsions, or
any other abnormalities.
• Milestones: motor, language, social, emotional psychosexual
• Childhood temperaments
 • Presence of neurotic symptoms: e.g. thumb sucking, bed wetting, temper tantrums etc.
• Academic history
• Sexual history
• Menstrual history
• Work history
• Patient’s family. Marriage, children, relationship, dynamics, presence of mental illness
or alcohol or drug abuse.
PREMORBID PERSONALITY
Characteristics possessed by a person that uniquely influences his or her cognitions, emotions,
motivations and behaviors in various situations.
 Hobbies and leisure activities
 Relationships- family, friends, work
 Mood-cheerful/gloomy; shows /hides emotions
 Character-Negative: shy, rigid ,sensitive, suspicious, self-centered, quarrelsome
/Positive: confident, punctual
 Attitude/Standards/Morality –body, health, religion, politics

Mental State Examination

General appearance and behavior:
• age group
• Built
• grooming, hygiene, dress, scars, tattoos
• Alertness, attitude towards examiner, level of communication,
• Facial expression, eyes
• psychomotor activity
• catatonic features, or any other abnormal movement
Talk or Speech
• Spontaneous or non-spontaneous;
• reaction time
• Rate
• tone; pitch; volume
• language understandable, goal directed, neologisms
Mood/Affect:
• Subjective(mood): in patient’s verbatim; pervasive and sustained emotional state
• Objective(affect): Examiner’s assessment; emotional state that is observed
 Type: euthymic (normal mood),depressed, irritable, anxious, elevated mood(euphoric,
elated)
 Range-normal, restricted, blunted, flat
 Stability- stable or labile
 Appropriateness to situation
 Congruency- appropriateness to thought
Thought:
Form: link between each thoughts
Loosening of association (LOA), Derailment
Rate of production: increased or decreased
Progression of thought: direction of flow
Flight of ideas (FOI), Circumstantiality, tangentially, perseveration, and thought block
Content of thought: Preoccupation; depressive ideas; Obsessional ideas, delusion
depressive ideas, Schneider’s first rank thought symptoms etc.
Preoccupation- centering of thought content on a particular idea associated with strong
affective tone.
Depressive ideas- negative thoughts- hopelessness, helplessness, worthlessness
Suicidal ideas, homicidal ideas
Worries
 Delusion- false, fixed, unshakeable belief firmly held in spite of contradictory evidence,
which is out of keeping from educational, socio-cultural background and pt. may act on
it.
Obsession- recurrent and intrusive thought, images or impulses that are inappropriate
and cause marked anxiety or distress
Schneider’s first rank symptoms
1. Three hallucinations
Thought echo, 3rd person hallucination, commentatory hallucination
2. Three thought problems
Thought broadcasting, thought withdrawal, thought insertion
3. Three made phenomenons
Made act, made affect, made impulse
4. Delusional perception
5. Somatic passivity
Perception:
Illusion: misinterpretation of actual external stimulus
Hallucination: false perception without an external stimulus, which is perceived as real
perception to the patient.
Attention and concentration:
The ability to focus in a sustained manner on a particular stimulus or activity.
Give examples. 100 minus 7 test; or 20 minus 3 test; counting till 20 and reverse; names
of months and days forward and then reversing
Memory:
Process by which information stored in brain is later recalled into consciousness.
1. Immediate retention and recall:
Test: Digit forward and backward (seven digits) [5 digit forward and 2 digit
backward may be considered as normal] or ask a pt. to try remember 3 nonrelated
items, test pt. after 5 mins.
2. Recent memory (of a few hours to few days ) and recent past memory( past few
months):
 Ask about food items taken especially vegetable this morning and last night.
Events happened within few months
3. Remote or Past: Major happenings in patients’ life e.g. marriage, passing of SLC, birth of
children, major national events like earthquakes, floods, change of governments, pro-
democracy movements etc.

Orientation:
Knowing state of oneself and surrounding in terms of time, place, person
a) Time: Time; period of day; day; date; week; month; year.
b) Place: Ward, hospital; home; area; city, town, village, district; zone, region, country,
continent.
c) Person: Doctor, informant, visitor, nurses and others.
Intelligence:
Ability to understand, recall, mobilize and constructively integrate previous learning in
meeting new situation
Average or below average. (Assess from education level, work performance, ability to
tackle novel situations on his/her own e.g. a young girl handling and unexpected guest
at home in absence of other family members etc.)
Judgment:
Ability to assess a situation correctly and to act appropriately in the situation
a) Social: Behavior during interview and other social settings.
b) Test: well stamped envelope test; or house on fire test or facing a snake
suddenly test.
Grasp of general knowledge: Names of well-known people e.g. prime minister; places; capitals;
tools etc.
Insight: Patient’s degree of awareness and understanding about being ill.
Do you think you have a problem?
What kind of problem do u think?
Do you need treatment?
Do you think treatment would do good?
What are your future plans?
Present/Partial/Absent