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Name
Age
Sex
Marital Status
Religion
Occupation
Socio-economic status
Address
Informant
Information (Relevant or not) adequate or not
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– In patient’s own words & in information’s
own words.
Eg: - Sleeplessness X 3 weeks
- Loss of appetite & hearing voices X 2 weeks
- talking to self X 2 weeks
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Onset - Acute (within a few hours)
-Subacute (within a few days)
- Gradual (within a few weeks)
Duration – days, weeks or months
Intensity / same / increasing or decreasing
Precipitating factors – yes / no (if yes explain)
History of current episode (explain in detail regarding the
presenting complaints)
Associated disturbances – include present medical
problems
(eg: Disturbance in sleep, appetite, IPR & social
functioning, occupation etc).
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Number of episode with onset & course
Complete or incomplete remission
Duration of each episode
Treatment details & its side effects if any
Treatment outcomes
Detail if any precipitating factors if present
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a) Past Medical History:
b) Past Surgical History
c) Obstetrical History (Female)
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Family genogram – 3 generations include only
grandparents.
But if there is a family history include the particular
generation
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Pre-natal history – Maternal infection
- Exposure to radiation etc.
– Check ups
– Any complications
Natal history: - Types of delivery
-Any complications
-Breath & cried at birth
Mile Stones: - Normal or delayed
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Behaviour during childhood:
- Excessive temper tantrums
- Feeding habit
- Neurotic symptoms
- Pica
- Habit disorders
- Excretory disorders etc.
Illness during childhood
- Look specifically for CNS infections
- Epilepsy
-Neurotic disorder
Malnutrition
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Schooling
- Age of going to school
- Performance in the school
-Relationship with teachers
(Specifically look for learning disability & attention deficit)
- Look for conduct disorders Eg. Truancy, stealing
Occupational history
- Age of joining job
- Relationship with superiors, subordinates & colleagues
- Any changes in the job – if any give detail
- Reasons for changing jobs
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Sexual history
- Age of attaining puberty (female-menstrual
cycles are regular)
-Source & extent of knowledge about sex, any
exposures
- Marital status: with genogram.
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(Personality of a patient consists
of those habitual attitudes & patterns of behaviour
which characterize an individual. Personality
sometimes changes after the onset of an illness.
Get a description of the personality before the
onset of the illness. Aim to build up a picture of
the individual, not a type. Enquire with respect to
the following areas)
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1. Attitude to others in social, family & sexual
relationship:
Ability to trust other, make & sustain
relationship, anxious or secure, leader or
follower, participation, responsibility, capacity to make
decision, dominant or submissive, friendly or emotionally
cold, etc. difficulty in role taking –
gender, sexual, familial.
2. Attitudes to self:
Egocentric, selfish, indulgent, dramatizing, critical, d
epreciatory, over concerned, self conscious, satisfaction or
dissatisfaction with work. Attitudes towards health &
bodily functions. Attitudes to past achievements &
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failure, & to the future.
3. Moral & religious attitudes & standards:
Evidence of rigidity or
compliance, permissiveness or over
consciousness, conformity, or rebellion. Enquire specifically
about religious beliefs.
4. Mood:
Enquire about stability of mood, mood swing, whether
anxious, irritable; worrying or tense. Whether lively or
gloomy. Ability to express & control feelings or
anger, anxiety, or depression.
5. Leisure activities & hobbies:
Interest in reading, play, music, movies etc. enquire
about creative ability. Whether leisure time is spent along or
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the circle of friends large or small?
6. Fantasy life:
Enquire about content of day dreams & dreams.
Amount of time spent in day dreaming.
7. Reaction pattern to stress:
Ability to tolerate
frustrations, losses, disappointments, & circumstances
arousing anger, anxiety or depression. Evidence for the
excessive use of particular defense mechanism such as
denial, rationalization, projection, etc.
8. Habits:
Eating, sleeping & excretory functions
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