CASE HISTORY
Socio-demographic Details:
a. Name
b. Age/ Sex
c. Registration No.
d. Educational Qualifications
e. Occupation
f. Socio-economic background- Rural/ urban/ sub-urban
g. Domicile- Lower/ Lower-middle/ middle/ higher
h. Family type- nuclear/ joint
i. Marital Status-
Number of children
j. Religion
Informants
Informant 1 Informant 2
Name
Age/Sex
Relationship with patient
Reliability of Information
Chief Complaints:
1.
2.
3.
4.
5.
Onset- Abrupt Acute Insidious
Course- Progressing Remission Fluctuating Static
Duration
Episode
Precipitating Factor
History of Present Illness
Biological Functioning:
1. Sleep
2. Appetite
3. Energy Level
Negative History
Past History
Family History
1. Family of Origin and Family Dynamics
2. Attitude of Family Members towards Illness
3. Family History of Psychiatric Illness
Personal History
1. Ante-natal
2. Natal
3. Post natal
4. Infancy and Childhood
5. Adolescence
6. Educational
7. Occupational
8. Marital
9. Sexual
10. Menstrual (for females only)
11. Substance use
Premorbid Personality/ Temperament (in case of Children)
1. Social Relations
2. Intellectual Activities, Hobbies and Interests
3. Predominant Mood
4. Character
a. Attitude to Self
b. Attitude to Work and Responsibility
c. Interpersonal Relationships
d. Standards in Moral, Religious and Health Matters
e. Energy and Initiative
5. Fantasy Life
6. Habits
MENTAL STATUS EXAMINATION
General Appearance and Behavior
Built
Accompanied by
Gait
Behaviour during interview
Dressing
Grooming
Eye contact
Cooperativeness
Rapport
Psychomotor Activity
Speech
Rate
Tone
Volume
Affect
Subjectively
Objectively
o Predominant affect
o Intensity
o Range
o Appropriateness
o Stability
Thinking
Flow (increased/decreased)
Form
o Relevant
o Coherent
Content
Perception
Cognition
Consciousness
Orientation
a. Time
i. Date
ii. Day
iii. Month
iv. Year
v. Season
vi. Time spent in hospital
b. Place
i. Present location
ii. Building
iii. City
iv. State
v. Country
c. Person
i. Name
ii. Informant’s Name
iii. Relationship with Informant
Attention
o Digit forward
o Digit backward
Concentration
o Days of the week-forward
o Days of the week –backward
o 20-1
o 40-3
o 100-7
Memory
o Immediate Retention and Recall (names of 3 things)
o Delayed Recall
o Recent Memory
i. How did you come to the room/hospital?
ii. What did you eat for breakfast/ lunch/ dinner today/ yesterday?
iii. Who came to meet you at the hospital or at home yesterday?
o Remote Memory
i.Date of birth
ii.Marriage anniversary
iii.Address
iv.Number of children
v.Names of children
vi.Number of years of work/schooling
vii.Place of work/schooling
viii.Major event that happened 2 years ago
Intelligence
i. General fund of knowledge
ii. Arithmetic
iii. Reading
iv. Writing
v. Comprehension
vi. Abstract thinking
o Proverb testing (3 proverbs)
o Similarities
o Differences
Judgment
Personal
Social
Test
Insight
i. Grade I (complete denial of illness)
ii. Grade II (slight awareness of being sick but denying at the same time)
iii. Grade III (Awareness of being sick, but it is attributed to external or physical
factors)
iv. Grade IV (Intellectual Insight)
v. Grade V (True Emotional Insight)
Provisional Diagnosis
