GEETANJALI COLLEGE OF NURSING

GEETANJALI UNIVERSITY, UDAIPUR RAJASTHAN

HISTORY TAKING FORMAT

1. IDENTIFICATION DATA
Name:
Age:
Sex:
Ward:
Admission Number:
Date of Admission:
Address:
Education:
Occupation:
Religion:
Marital Status:
Language:
Nationality:
Consultant:
Informant:
Reliability of Informant:
 Relevant/ not relevant
 Reliable/ Unreliable
 Adequate/ inadequate
 Relationship with the patient
 Health status of the informant

2. PRESENTING CHIEF COMPLAINTS: With duration in chronological order, patient’s own

words and informant’s own words)
 According to patient: (Verbatim manner)
 According to informant:

3. HISTORY OF PRESENT ILLNESS: (In narrative form)

 Duration: Days/ weeks/ months/ years.
 Mode of onset: Abrupt/ acute/ sub-acute/ insidious.
 Course: Continuous/ episodic/ fluctuating/ deteriorating/ improving/ unclear.
 Intensity: Same/ increasing/ decreasing.
 Precipitating factors: Yes/ no, if yes explain.
 Description of present illness: Chronological description of abnormal behavior, associated
problems like suicide, homicide, disruptive behaviour; thought content, speech, mood states,
abnormal perception, biological functioning, social functioning, occupational functioning,
changes in ADLs.
 4. HISTORY OF PAST ILLNESS: (It includes medical history, surgical history, psychiatric
history)
 Number of previous episodes/ hospitalization (psychiatric) with onset and course.
 Complete or incomplete remission.
 Duration of each episode.
 Treatment details and its side effects if any.
 Treatment outcome.
 Detail of any precipitating factors if present.
 Substance use details.
 Surgical procedures/ accidents/ head injury/ convulsions/ unconsciousness/ DM/ HTN/ CAD/
venereal disease/ HIV positivity/ any other.

5. HISTORY OF FAMILY :
 Family Tree: Based on family of origin and family of procreation.
 Family Details: Describe each family member briefly: age, education, health status,
occupation, relationship with the patient, age at death, mode of death.
 Family history of mental illness: Mental retardation, epilepsy, alcoholism and other substance
abuse, renouncing world in grandparents, aunts, first cousins, siblings and children and other
psychiatric disorders.

6. PERSONAL HISTORY:(Patient’s childhood, relationship between parents, socio-economic

status, interpersonal relationships)

Prenatal history and mother’s pregnancy and delivery: (DOB, length of pregnancy, spontaneity and
normality of delivery, birth trauma, whether patient was planned and wanted child, birth defects).

a) Infancy
 Feeding habits: (Breast- fed or bottle- fed, eating problems).
 Early development: (Maternal deprivation, language development, motor development, signs
of unmet needs, sleep pattern, object constancy, stranger anxiety).
 Toilet training: (Age, attitude of parents, feeling about it).
 Symptoms of behavior problems: (Thumb sucking, temper tantrums, tics head bumping,
rocking, night terrors, fears, bed wetting, bed sores, nail biting, masturbation).
 Personality and temperament as a child: (Shy, restless, overactive, withdrawn, studious,
outgoing, timid, athletic, friendly patterns of play, reactions to siblings).

b) Childhood

Early school history, separation anxiety, gender identification, conscience development, punishment,
social relationships, attitude towards siblings and playmates.
c) Late Childhood ( Prepuberty Through adolescence )

 Peer relationships: (number and closeness of friends, leader or follower, social popularity,
participation in group and gang activities, idealized figures, patterns of aggression, passivity,
anxiety, antisocial behavior.
 School history: (How far the patient studied, adjustment to school, relationships with teachers
pet or rebellious, favourite studies or interests, particular abilities or assets, extracurricular
activities, sports, hobbies, relationships of problems or symptoms to any school period).
 Cognitive and motor development: (Learning to read and other intellectual and motor skills,
minimal cerebral dysfunction, learning disabilities- their management and effects on the child).
 Particular adolescent emotional or physical problems: (Nightmares, masturbation, bed-wetting,
running away, delinquency, smoking, drug, or alcohol use, weight problems, feeling of
inferiority).
 Psychosexual history: (Early curiosity, infantile masturbation, sex play acquiring of sexual
knowledge, attitude of parents towards sex, sexual abuse, onset of puberty, feelings about it, kind
of preparation, feelings about menstruation, development of secondary sexual characteristics,
adolescent sexual activity, crushes, parties, dating, petting, masturbation, wet dreams and
attitudes toward them).
 Attitudes towards same and opposite sex: (Timid, shy, aggressive, need to impress, seductive and
anxiety).
 Sexual practices: (Sexual problems, homosexual and heterosexual experiences, paraphilias and
promiscuity).
 Religious background: (Strict, liberal, mixed or possible conflicts, relation of background to
current religious practices).

d) Adulthood
 Occupational history: (choice of occupation, training, ambitious, conflicts, relations with
authority, peers, and subordinates, number of jobs and duration, changes in job status, current job
and feelings about it).
 Social history
 Adult sexuality: (Premarital sexual relationships, sexual orientation, sexual symptoms like
impotence, premature ejaculation and lack of desire, attitudes towards pregnancy and having
children, sexual practices and marital history chart).
 Religion
 Present living situation
 Alcohol and drug abuse

7. PREMORBID PERSONALITY
a) Social relations
 To family
 To friends
 Groups
 Society
  Clubs
 To work and workmates (leader or follower, organizer, aggressive, submissive, ambitious,
adjustable and independent).

b) Intellectual activities
 Hobbies and interests
 Books, plays
 Pictures preferred
 Memory
 Observation
 Judgment
 Critical faculty

c) Mood
 Bright and cheerful, or despondent
 Worrying or placid
 Strung up or calm & relaxed
 Optimistic or pessimistic
 Self-depreciative or satisfied
 Mood stable or unstable(with or without any occasion)

d) Character

Attitude to work and responsibility: (Welcomes or is worried by responsibilities, makes decision easily
or with difficulty, haphazard or methodical and meticulous, rigid or flexible, preserving and determined,
easily bored and discouraged).

Interpersonal relationships: (Self- confident or shy and timid, insensitive or touchy and sensitive to
criticism, trusting or suspicious and jealous, emotionally controlled or quick tempered and irritable,
tactful or outspoken, enjoys or shuns self- display, expressive and demonstrative in speech and gesture,
interests and enthusiasms sustained and adaptable or unadoptable.

Standards in morale, religious, social and health matters: (Level of aspiration high or low,
perfectionistic and self- critical or complacent, self-approving in relation to own behavior and
achievement, selfish and egoistical or selfish and altruistic, steadfast in face of difficulties or intolerant of
frustration, given too much or little concern about own health.

e) Fantasy life
f) Habits
 Eating
 Alcohol consumption
 Self-medication with drugs or other medicines
 Specify amounts taken recently and earlier
 Sleeping and excretory functions

IMPRESSION: WELL ADJUSTED/ ANY SPECIFIC TRAITS