PROTOTYPE PSYCHIATRIC HISTORY AND EXAMINATION

A. GENERAL INFORMATION:
NAME:
AGE: SEX: OCCUPATION:
MARITAL STATUS:
REFERED BY:

B. HISTORY OF PRESENTING COMPALNT:

(List complaints of this episode in patient’s words, duration, severity, associated
problems, precipitating factors)

C. PAST PSYCHIATRIC HISTORY:

(Duration of illness, number/duration of admission, complaints on admission, treatments
given)

D. PAST AND CURRENT MEDICAL HISTORY:

(Childhood illnesses, operations, injuries, current medication)

E. FAMILY HISTORY:
1. Father age: occupation:

(If deceased-date, age and cause of death)

Personality:

Relationship with:

2. Mother age: occupation

(If deceased-date, age and cause of death)

Personality

Relationship with:

3. Siblings: patients position in sibship

a) brothers
b) sisters
4. Family history of psychiatric disorder:

F. PERSONAL HISTORY:
1. Date and place of birth:
2. Early development:
 3. Health during childhood:
4. Neurotic traits:
5. School record:
6. Work record:
7. marital adjustment:

G. PREMORBID PERSONALITY:
1. Social relations:
2. Intellectual activities:
(Interests, hobbies etc)
3. Mood:
4. Character:
a) Attitude to work and responsibility:
b) Interpersonal relationship:
c) Standards in moral, religious, social and health matter
d) Energy initiative:
5. Fantasy life:
6. Habits: (alcohol etc)

H. MENTAL STATE:
 Appearance and behavior:

 Level of consciousness:

 Speech:

 Mood: Subjective-
Objective-
Suicide-

 Thought content:
(Preoccupations, phobias, obsessions, worries etc)

 Abnormal beliefs:

 Disorder of perception:

 Attention and concentration:

 Orientation:
  Memory: Short-term-
Long-term-

 General information:

 Estimate of general intelligence:

 Insight:

I. DIAGNOSIS: (Based On DSM 5-TR)

J. MANAGEMENT PLAN:
1. Investigation (includes collateral history):
2. Treatment:
3. Biological:
4. Psychological:
5. Social:
6. Physical examination: