STUDENTS IDENTIFICATION

Name Of Institute:-
________________________________________________
________________________________________________
Name of student:-
________________________________________________
Batch:-
________________________________________________
Name Of Clinical area:-
________________________________________________
Name Of Patient:-
________________________________________________
Registration No :-
________________________________________________
Date Of Admission:-
________________________________________________
Final diagnosis :-
________________________________________________
Date of Selection Of Patient:-
________________________________________________
Type of assignment:-
________________________________________________
Submitted to:-
________________________________________________
IDENTIFICATION OF THE PATIENT:
Name of the patient: -
_______________________________________________________
Age : - _________________ Sex :- ______________________
Date of admission : -__________Registration No:-____________
Address:-
_______________________________________________________
_______________________________________________________
Unit in charge: - _________________ Ward no.:- __________
Religion: - _________Marital status:-________________________
Education : - ___________________________________________
Occupation:-_____________________________________________
Socio-economic status: - ___________________________________
Income: -________________________________________________
Habitat: ________________________________________________
Language: - _________________Weight: - ____________________
Height: - _______________________________________________
Informant: -
________________________________________________________
Provisional diagnosis: -
________________________________________________________
Final diagnosis:-__________________________________________
Criteria of diagnosis: -
________________________________________________________
INFORMANT:-
Name: -
Age: - Sex: -
Address: - Religion: -

Education: -

Income: -

Relationship with patient:-

Reliability: -

Intimacy with patient: -

Familiarity with patient: -

Length of stay with patient: -

Attitude towards patient: -

Bias with patient: -

Marital status:-

Occupation: -

Socio-economic status: -

Interest of informant in the patient’s property or money: -

Ability to report pervious episode:-

I) Presenting Complains:-
H/o Present illness:-

Duration:-

Mode of Onset:-

Precipitating Factors:-

Treatment Prescribed:-
A) General Appearance and Grooming:-
Dress with neatness:-

Tidy and clean:-

Cloths appropriate to season:-

Nails, Hair and Grooming:-

Concern about appearance and hygiene:-

B) Attitude:-

C) FACIAL EXPRESSION:-

D) Posture:-

G) Gait:-
H) Body Built:-

I) Gesture:-

Grimace:-

Mannerism:-

Tic:-

J) Behaviour:-

In the ward with other patients and self:-

Visitors, at time of meal, at a time of sleep:-

Aggressive:-

Abusive:-

Assaultive:-

II) PSYCHOMOTOR ACTIVITIES:-

III) VOICE AND SPEECH:-
a) Intensity :-

b) Pitch :-

c) Volume :-

d) Spontaneity :-

e) Relevancy :-

f) Productivity :-

g) Ease of speech :-

h) Manner :-

Deviation if any :-

IV) MOOD AND AFFECT:-

a) Mood:-

b) Affect:-
 V) Thought:-
a) Nature :-

Sr.No Question Answer Inference

b) Form

Sr.No Question Answer Inference

c) Stream

Sr.No Question Answer Inference

 D) Possession:-

Assess Question Answer Inference

Thought

Control

Withdraw
l Of
Thought

Thought
Insertion

Thought
Brodcast

E) Content:-

Assess Question Answer Inference

Delusion Of
Reference

Delusion Of
Grander

Delusion Of
Persecution

Delusion Of
Control
 Delusion Of
Guilt

Delusion Of
Hypochondriasis

Delusion Of
Love

Delusion Of
Nihilism

Delusion Of
Infidility

Delusion Of
Fantasy

F) Obsession :-

Sr Question Answer Inference

No.

G ) Phobia :-

Sr Question Answer Inference

No.
 H ) Suicidal Thoughts :-

Sr Question Answer Inference

No.

VI) Perception:-
1) Hallucination:-

Type Question Answer Inference

Auditory

Hallucinatio
n

Visual
Hallucinatio
n

Olfactory
Hallucinatio
n
Tactile
Hallucinatio
n
Kinesthetic
Hallucinatio
n
Gustatory
Hallucinatio
n
Command
Hallucinatio
n

2) Illusion:-

Sr Question Answer Inference

No.

3) Depersonalization, if any:-

Sr Question Answer Inference

No.

4) Derealisation, if any:-

Sr Question Answer Inference

No.
 VII) COGNITION AND SENSETION:-

a) Orientation:-

Content Question Answer Inference

Time

Place

Person

b) Memory:-

Content Question Answer Inference

Immediat
e

Recent

Remote
 C) Attention and concentration :-

Sr no. Question Patient answer Inference

Forward
digit span
Test

Backward
digit span
test

Serial
subtraction

Days or
months
counting

D) Abstract thinking:-

Content Question Answer Inference

Similarity

Difference
Proverb
Testing

E) Intelligence:-

Content Question Answer Inference

General
information

Comprehension

Arithmetic

F) JUDGEMENT:-

Content Question Answer Inference

Personal

Family
 Social

Employment

Test /
situational

G) INSIGHT:-

Sr. Grading Patient answer Inference

No.
1 Complete Denial Of Illness

Slight Aware Of Being Sick

2
3 Awareness Of Being Sick
Attributed It To External/Physical
Factor
4 Awareness Of Being Sick But Due
 To Some Unknown In Himself
5 Intellectual Insight
6 True Emotional Insight

X) BIODRIVES AND GENERAL OBSERVATION:-

Content Question Answer Inference

Appetite

Sleep

Sexual
drive
(Libido)

Elimination
SUMMERY AND CLINICAL DIAGNOSIS OF
MENTAL STATUS EXAMINATION :-