HISTORY OF MY PATIENT

 DEMOGRAPHIC DATA-
 NAME :-
 AGE :-
 SEX :-
 MARITAL STATUS :-
 RELIGON :-
 DATE OF ADMISSION :-
 CONSULTANT :-
 OCCUPATION :-
 SOCIOECONOMIC :-
 EDUCATION :-
 ADDRESS :-
 INFORMATION :-
 INFORMANT :-
 DIAGNOSIS :-

 CHIF COMPLAINT :-

 PRESENT PSYCHIATRY HISTORY :-

 ONSET :
 DURATION :
 COURSE :
 INTENSITY :
 PRECIPITATING DACTORS :
 ASSOCIATED DISTURBANCES :
 HISTORY OF CURRENT EPISODE :
 PAST PSYCHIATRY HISTORY :-
 NUMBER OF EPISODES WITH THE ONSET AND COURSE :
 DURATION OF EACH EPISODE :
 TREATMENT DETAIL AND ITS EFFECT IF ANY :
 TREATMENT OUTCOME :
 DETAIL IF ANY PRECIPITATING FACTORS ARE PRESENT :

 PAST MEDICAL & SURGICAL HISTORY & OBESTETRIC HISTORY –

 PAST MEDICAL HISTORY -

 PAST SURGICAL HISTORY -

 OBSTETRIC HISTORY -

 FAMILY HISTORY –
 PERSONAL HISTORY –

 PRENATAL HISTORY :
 Material Infection -
 Exposure to radiation -
 Checkups -
 Any physical or psychiatric illness during pregnancy -
 Wanted or unwanted child –
 Any complication -
 NATAL HISTORY-
 Type of Delivery -
 Breath and cried at birth -
 Neonatal Infection -
 Any abnormality -
 MILESTONE – Normal/Abnormal

 BEHAVIOUR DURING CHILDHOOD -

 Exercise temper tantrum –
 Feeding habit -
 Neurotic symptoms -
 Pica -
 Habit disorder -
 Excretory disorder -

 ILLNESS DUING CHILDHOOD –

 Looking specially for CNS infection –
 Epilepsy –
 Neurotic disorder -
  MALNUTRITION

 SCHOOLING-
 Age of going school -
 Performance in school -
 Relationship with peers -
 Relationship with teachers -
 Look for conduct disorder -

 OCCUPATION –
 Age of joining job -
 Relationship with superior, subordinates, and colleague -
 Reason for leave job -

 SEXUAL HISTORY-
 Age of attaining puberty -
 Source and extent of knowledge sex -
 Marital history -

 PREMORBID PERSONALITY –

 Interpersonal relationship : -

 Attitude to self :
 Moral and Religious and Standards :

 Mood :

 Leisure activities and hobbies

 Fantasy Life :-

 Reaction Pattern to Stress :-

 Habits :-
 Eating -
 Alochol -
 Tobacco -
 Sleeping -
 Excretory Function -

SUMMARY :
 *Physical Examination*
 General Survey
(a) Vital Signs
 Temperature -
 Pulse -
 Respiration -
 Blood Pressure -
 Height -
 Weight -
 Body Built -

Moderate
 Posture & gait -
Normal
 Hygiene -

Average
 Mental status -

Skin
 Color -
 Cyanosis -
 Erythema -
 Edema -
 Lesion -
Hair’s
 Color -
 Distribution -
  Dry/oily -
Nails

 Plate Shape -

 Color & Nail Bed -

 Clubbing -

 Nail Texture -

The Head

 Skull & face -

 Circumference -

 Shape -

 Tremors -

Eye

 Eye Vision -

 Eye brows -

Distribution -

Color -

 Eye Lids -

Symmetry -

inflammation -

Edema -

 Extremities -

Upper -

Lower -
 MINIMENTAL STATUS EXAMINATION

The Folstein mini mental status examination is a preferred tool for

assessing the mental status of the client with suspected cognitive
impairments.
The perform the examination asks the client to follow a series of simple
command that test the ability to understand and perform cognitive
functions. Award a designated point value for successful completion of
each instruction. Than total the score to determine the client mental
status score of 26-30 indicates the client has normal function 22-25
middly impaired and less than 22 significantly impaired.

IDENTIFICATION DATA :

Name -

Age -

Sex -

Education -

Occupation -

Nationality -

Religion -

Marital status -

Address -
S.N MAXIMUM MINIMUM
CLIENT INSTRUCTION
o. SCORE SCORE

ORIENTATION (5)
 Ask the client name the year, season, date, day,
and month. (Score one point for each correct
response) 1
 What is the year 1
 What is the season
1
 What is the date
 What is the day of week 1
1
 What is the month 1
(5)
 Ask the client name
 The name of the state he/she belong 1
 The name of the city 1
 The street name & number 1
 House address
1
 Room in which he/she is standing
1
(3)
REGISTRATION
 Pen 1
2
 Copy 1
 Key 1
(5)
ATTENTION AND CALCULATION
Ask the client to count at 100 1
Count from 1-20 1
3 Count backward by 20
1
Count five number alternative
Ask to identify the number 1
Ask to spell the work 1

RECALL : (3)
Ask the client to restore the name of the object 3
previously identified in the examination (Score 1 point
4
for each correct response)
 Pen 1
 Copy 1
  Key 1
LANGUAGE : (9)
 Point towards pencil and watch and name
them 2
 Repeat “NO” id and up 1
 3 stage command (3)
5 1. Sit down 1
2. Stand up 1
3. Show your teeth 1

 Write “Close Your eyes” 1

 Write sentence of your choice 1

 Draw figure (Square) 1

TOTAL 30

SUMMARY :
 MENTAL STATUS EXAMINATION
(1) GENERAL APPEARANCE :
 Personality :
 Posture :
 Clothing and grooming :
 Overt behavior and psychomotor activity :
 Mannerism :
 Tics :
 Stereotype movement :
 Echopraxia :
 Hyperactivity :
 Agitation :
 Rigidity :
 Waxy flexibility :
(2) SPEECH:
 Quantity :
 Rate of production :
 Volume :
 Reaction time :
 Quality :
 Tone :
 Relevant :
 Coherence :
 Other :
(3) MOOD AND AFFECT :
 Mood-

1. Elevated-

Q.

A.

Outcome-

2. Depressed

Q.

A.

Outcome-
 1. Anxious :
2. Euphoric :
3. Ecstasy :
4. Guilt :
5. Elation :
6. Expansive :

AFFECT
1. Appropriate Affect :
2. Inappropriate affect :
3. Blunted affect :
4. Restricted affect :
5. Flat affect :
(4) THINKING
 Form of Thought
1. Neologism –
Q.
A.
Outcome –
2. Word salad
Q.
A.
Outcome-
3. Circumstantialities
Q.
A.
Outcome-
4. Tangentiality
Q.
A.
Outcome-
5. Incoherence
Q.
A.
Outcome-
6. Perseveration
Q.
A.
Outcome-
7. Echolalia
Q.
A.
Outcome-
8. Irrelevant
Q.
A.
Outcome-
9. Loosenting of association
Q.
A.
Outcome-
10. Flight of ideas
Q.
A.
Outcome-
11. Clang association
Q.
A.
Outcome-
12. Thought blocking
Q.
A.
Outcome-
(5) Content of thought
1. Poverty of content
Q.
A.
Outcome-
2. Overvalued ideas
Q.
A.
Outcome-
DELUSION
1. Delusion of poverty
Q.
A.
Outcome-
2. Nihilistic delusion
Q.
A.
Outcome-
3. Somatic Delusion
Q.
A.
Outcome-
4. Delusion of Persecution
Q.
A.
Outcome-
5. Delusion of grandiose
Q.
A.
Outcome-
6. Delusion of reference
Q.
A.
Outcome-
 7. Delusion if infidelity
Q.
A.
Outcome-
(6) Thought alienation
1. Thought withdrawal
Q.
A.
Outcome-
2. Thought insertion
Q.
A.
Outcome-
3. Thought Broad casting
Q.
A.
Outcome-
4. Hypochondriac Delusion
Q.
A.
Outcome-
5. Thought Control
Q.
A.
Outcome-
6. Obsession-
Q.
A.
Outcome-
7. Compulsion-
Q.
A.
Outcome-
 8. Phobia-
Q.
A.
Outcome-
9. Preoccupation of thought-
Q.
A.
Outcome-
(7) PERCEPTION:
 Hallucination-
1. Auditory hallucination
Q.
A.
Outcome
2. Visual hallucination
Q.
A.
Outcome-
3. Olfactory hallucination
Q.
A.
Outcome-
4. Gustatory hallucination-
Q.
A.
Outcome-
5. Tactile Hallucination-
Q.
A.
Outcome-
  Illusion-
1. Derealisation-
Q.
A.
Outcome-
2. Depersonalization-
Q.
A.
Outcome-
3. Micropsia-
Q.
A.
Outcome-
4. Macropsia-
Q.
A.
Outcome-
(8) SENSORIUM :
1. Attention-
 Black word
Q.
A.
Outcome-
 Back ward-
Q.
A.
Outcome-
2. Alertness-
Q.
A.
Outcome-
3. Concentration-
Q.
A.
Outcome-
4. Orientation-
Q.
A.
Outcome-
5. Memory level of memory
 Immediate
Q.
A.
Outcome-
 Recent
Q.
A.
Outcome-
 Remote-
Q.
A.
Outcome-
6. Disturbance in memory-
 Amnesia-
Q.
A.
Outcome
7. Blackout-
Q.
A.
Outcome-
 8. Intelligence-
 General information-
Q.
A.
Outcome-
 Comprehensive-
Q.
A.
Outcome-
 Arithmetic-
Q.
A.
Outcome-
 Abstraction-
 Similarity-
Q.
A.
Outcome-
 Difference-
Q.
A.
Outcome-
 Proverb-
Q.
A.
Outcome-
(9) INSIGHT:
1. Intellectual:
Q.
A.
Outcome-
 2. True-
Q.
A.
Outcome-
3. Impaired-
Q.
A.
Outcome-

(10) JUDGEMENT:
1. Personal-
Q.
A.
Outcome-
2. Social-
Q.
A.
Outcome-
3. Test-
Q.
A.
Outcome-
(11) SUMMARY: