TOWN HILL HOSPITAL

Hyslop Road, Pietermaritzburg, 3201

PO Box 400, Pietermaritzburg, 3200 GENERAL ADULT PSYCHIATRY:
Tel: 033 341 5500, Fax 033 345 5720 PSYCIATRIC ASSESSMENT FORM

PSYCHIATRIC ASSESSMENT

DEMOGRAPHICS
NAME HOSPITAL No:
DATE OF BIRTH
AGE GENDER
RACE MARITAL STATUS
ADDRESS

EMPLOYMENT EMPLOYED
UNEMPLOYED PENSION MEDICAL BOARDING
Specify: DG

LEVEL OF EDUCATION LANGUAGE

RELIGION HANDEDNESS
MHCA STATUS VOLUNTARY ASSISTED INVOLUNTARY
NAME AND CONTACT DETAILS OF
RELATIVE/FRIEND

ROUTE OF REFERRAL
NAME RELATIONSHIP CONTACT NO

PRESENTING COMPLAINT

HISTORY OF PRESENTING COMPLAINT (onset of symptoms, precipitant and temporal relationship, duration, evolution of
symptoms, aggravating and relieving factors, associated medical and psychiatric, response to medication symptoms)
 SYSTEMIC ENQUIRY (other relevant symptom clusters which may suggest another disorder e.g. mood, anxiety, psychotic, eating,
substance use, cognitive, personality)

PAST PSYCHIATRIC HISTORY

FIRST ILLNESS EPISODE
FIRST CONTACT WITH PSYCHIATRY,
PSYCHOLOGY, TRADITIONAL HEALER

PREVIOUS PSYCHIATRIC DIAGNOSIS

NO. AND DETAILS OF PREVIOUS ILLNESS

EPISODES (precipitants, duration, severity,
response to treatment, duration of remission)

NO. AND DETAILS OF ADMISSIONS

(MHCA status, duration, treatments; Date of most
recent admission)

PREVIOUS RESPONSE TO TREATMENT

(pharmacological, psychological, social.)
(previous ECT)

ADHERENCE
DETAILS OF PREVIOUS
SUICIDE ATTEMPTS AND
SELF-HARM

PAST MEDICAL/ SURGICAL/ GYNAE HISTORY

NEUROLOGICAL (head trauma, epilepsy,

delirium, CNS infections, head aches)

NON-NEUROLOGICAL (diabetes, hypertension,

thyroid disease, GORD, asthma, TB, HIV, syphilis,
cardiac disease, renal failure, liver disease)

GYNAECOLOGICAL/OBSTETRIC
(contraception; pregnancy status/LMP)
PREVIOUS SURGERIES
ALLERGIES
PAST AND CURRENT TREATMENTS
 DRUG AND ALCOHOL HISTORY (onset, precipitant/s, amount, effects, pattern of use, features of abuse and dependence, medical and
psychiatric complications, attempts to stop, stage of change)

CIGARETTES (nicotine)

ALCOHOL

CANNABIS

OTHER DRUGS

CAFFEINE

OTCs AND PRESCRIPTION RX

ENVIROMENTAL/
OCCUPATIONAL EXPOSURE

FORENSIC HISTORY (cautions, charges, convictions, prison sentences, pending court cases, screen for antisocial behaviour)

FAMILY HISTORY

GENOGRAM

MENTAL ILLNESS (incl. suicide

and substance use)

MEDICAL ILLNESS (incl.

epilepsy)

NATURE OF RELATIONSHIPS
(parents, siblings, spouse/partner,
children)
 PERSONAL HISTORY
DEVELOPMENTAL
PREGNANCY (planned vs unplanned, mother’s mental state,
substance use, intrauterine infections, mode of delivery,
complications of labour, neonatal complications)

MILESTONES
PROBLEMS: (Illness/physical trauma/abuse/neglect.
Parental separation, parental violence
Enuresis, encopresis
Traumatic events)

EDUCATIONAL
AGE IN GRADE 1
TYPE OF SCHOOLING
PRIMARY SCHOOL
SECONDARY SCHOOL
TERTIARY EDUCATION
PROBLEMS (academic e.g. learning difficulties/failures,
bullying, separation anxiety, school refusal, truancy, conduct
disorder symptoms, ADHD)

PROTECTIVE FACTORS (friendships, sports, hobbies,

enjoyment of school)

OCCUPATIONAL (First job, number of and duration of subsequent jobs, reasons for leaving, most recent job, problems e.g.
discrimination, fired, mental and physical health hazards, medical boarding, disability grant)

PSYCHOSEXUAL AND RELATIONSHIPS (current relationship status, previous relationships, domestic violence, sexual orientation,
sexual problems, previous sexual trauma, number of sexual partners, number of pregnancies and complications, children)

CURRENT SOCIAL CIRCUMSTANCES:

ACCOMMODATION: (water, electricity,
overcrowding, employment, income)

FUNCTIONING: ADLs and IADL

SUPPORT: (family, friends, colleagues, religious
organisations, hobbies/finances)

PREMORBID PERSONALITY (self-description, hobbies and interests, religious affiliation, spiritual beliefs, cultural
influences, coping skills, reaction to stress)
 MENTAL STATE EXAMINATION

APPEARANCE AND BEHAVIOUR (self-care: grooming, hygiene, nutrition, dress, cooperation, rapport, posture, eye
contact, involuntary/abnormal movements, disinhibition)

SPEECH (rate, tone, volume, clarity, grammar, syntax, rhythm)

MOOD (dysphoric, euthymic, expansive, irritable, labile, elevated, euphoria, etc.)

SUBJECTIVE

OBJECTIVE

AFFECT (range, stability, congruency)

THOUGHT
FORM (neologisms, word salad, circumstantiality, tangentiality, incoherence, perseveration, verbigeration, echolalia,
irrelevant, loosening of association, derailment, flight of ideas, clang association, blocking)

CONTENT (overvalued ideas, delusions, preoccupations, ruminations, obsessions, phobias, negative thinking, poverty, passivity
phenomena, suicidal ideation)

PERCEPTION
HALLUCINATIONS
(hypnogogic, hypnopompic, auditory, visual,
olfactory, gustatory, tactile)

ILLUSIONS
DEPERSONALIZATION
DEREALISATION
 COGNITION
ORIENTATION

ATTENTION

CONCENTRATION

PROCESSING SPEED
MEMORY
(short term and long term)

LANGUAGE (expressive: word finding

and naming receptive: following
instructions; reading and writing)
EXECUTIVE FUNCTION
(planning, organization, prioritizing,
abstract thinking, impulsivity)

OTHER BEDSIDE TESTS

INSIGHT (acceptance and understanding of mental illness, attitude towards treatment, etc.)

JUDGEMENT (how does the clinical status impact on decision making or actions that have safety implications?)

PHYSICAL EXAMINATION
GENERAL
VITAL TEMP PULSE BP RESP
SIGNS RATE
WEIGHT
HYDRATION
EPSE
THYROID
DENTATION
STIGMATA OF
HIV
OTHER

SYSTEMIC EXAMINATION
CHEST

CVS

ABD

CNS (GCS,
cranial nerves,
pupils, motor,
sensory, co-
ordination, gait)
CASE SUMMARY: (brief (3-4 sentences) summary of: Demographics/Relevant past psychiatric, medical, substance use, forensic, family,
personal/ History of presenting complaint/ Relevant mental state, cognitive testing and physical examination findings)

CASE FORMULATION:
DIAGNOSTIC FORMULATION
DIFFERENTIAL DIAGNOSIS (Provide a DSM-5 differential diagnosis listing most likely (or principal) diagnosis first and providing
motivation for each diagnosis and reasons for discounting differential diagnosis in favour of principal diagnosis)
FINAL DSM 5 DIAGNOSIS (include psychosocial and contextual factors if it is a focus of clinical attention and a reason for
the current admission, special investigations or management)

PSYCHOSOCIAL AND CONTEXTUAL FACTORS: (any important psychosocial and contextual factors that are a focus of clinical
attention and a reason for the current admission, special investigations or management.)

DISABILITY (√)
Understanding and Household activities Self-care
communicating
Participation in society School/work activities Getting along with people
COMMENT BRIEFLY:

RISK ASSESSMENT (low/medium/high)

TO SELF suicide impulsivity abscondment
deliberate self-harm substance misuse non-adherence
COMMENT: (Immediate and long term, include the reasons for your assessment)

TO OTHERS (violence, homicide)

BY OTHERS

PROPERTY
 AETIOLOGICAL FORMULATION
(present as a narrative not a checklist)
CULTURAL/
BIOLOGICAL PSYCHOLOGICAL SOCIAL SPIRATUAL.
( incl. cultural expression of
symptoms, perceptions of
illness causation/factors
that may be impacting on
treatment-seeking and
treatment)

PREDISPOSING

PRECIPITATING

PERPETUATING

PROTECTIVE
MANAGEMENT

SETTING BIOLOGICAL PSYCHOLOGICAL SOCIAL

RISK (out-pt./in-pt.;
MANAGEMENT MHCA/ hospital
PLAN level)

HIV PLAN
TB PLAN
STI PLAN
(Investigations/ Monitoring/ (Screening tolls/ (Collateral/ social services/ care
Emergency medical Psychoeducation/ supportive of dependents)
IMMEDIATE management/Detox) counselling)

Appropriate use of medication/ (Plan regarding appropriate (OT- specified intervention

monitoring plan/dietitian) therapy) SW – specify intervention)
MEDIUM TERM

LONG TERM
 PROGNOSIS (support, substance misuse, co-morbidity, insight, adherence, physical illness, family and community influence)
SHORT TERM:

GOOD PROGNOSTIC POOR PROGNOSTIC

FACTORS FACTORS

LONG TERM:

REFERALS MADE/ INVESTIGATIONS BOOKED:

OTHER NOTES: (collateral on admission/ d/w consultant/ d/w another health care professional)

NAME OF DOCTOR SIGNATURE

DATE TIME