NIMHANS PROFORMA

[Document subtitle]

[DATE]
[COMPANY NAME]
[Company address]
HISTORY TAKING

I. COMPLAINTS AND DURATION (patient and informant)

 Received in chronological order.
 Do not write a long list of complaints.
 Ask direct questions if they don’t respond.
 Use your skills for discretion and eliciting.

II. HISTORY OF PRESENTING ILLNESS

Give a detailed account of symptoms from onset to the time of consultation including their
chronological evolution and course.
 ONSET:
 Acute – developing within a few hours
 Sub acute – few days to few weeks.
 Gradual – few weeks to few months.
 PRECIPITATING FACTORS:
 Physical – febrile illness
 Psychological- death, loss
Ascertain whether events clearly proceed or were consequences of illness.
 COURSE OF ILLNESS:
 Episodic- discrete symptomatic periods with intervening periods of normalcy.
 Continuous
 Fluctuating- periodic exacerbations of a continuous illness.
A different pattern of symptoms may evolve in a continuous illness.
For e.g., delusions, hallucinations, intense affect may be prominent in initial
phase while in later stages apathy and emotional blunting might be
prominent.
Graphic presentation of the course of illness is very informative.
 ASSOCIATED DISTURBANCES
 Disturbances in sleep, appetite, weight, sexual life, social life, occupation and
evidence of secondary gain.
 The specific nature of disturbances and degree of disability to be noted.
 HISTORICAL DETAILS:
 History of trauma fever headache vomiting confusion disorientation memory
disturbances physical illness like hypertension diabetes and history of
substance abuse.
 Treatment of the illness.
III. PAST HISTORY
 Past psychiatric illness – nature and duration of symptoms, treatment
received, pattern of response and degree of compliance.
 Past physical illness- epilepsy, hypertension, diabetes, tuberculosis, head
injury, asthma and any other medical illness.

IV. FAMILY HISTORY

 Description of the individuals family members , parents and siblings.
 Whether they are living or dead, age ,education, occupation, marital status,
personality and relationship with the patient.
 Socioeconomic status of the family.
 Leadership pattern
 Role functions and communications within the family.
 Physical and psychiatric illness within the family.
V. PERSONAL HISTORY
I. Birth and early development:
Prenatal, natal, postnatal details- gestational period, place of birth,
complications during delivery, physical illness during postnatal period,
milestones of development
II. Behaviour during childhood:
Sleep disturbances, thumb sucking, nail biting, temper tantrums, bedwetting,
stammering, tics and mannerisms.
Conduct disorders in the form of fights, truancy, stealing and lying and gang
activities.
III. Relation with parents , siblings and peers.
IV. Physical illness during childhood like epilepsy, meningitis and encephalitis.
V. School:
Age of beginning and finishing school, type of school, scholastic performance,
attitude towards teachers and peers.
VI. Occupation:
Age of starting work, jobs held in chronological order, work satisfaction,
competence, future ambitions.
VII. Menstrual history:
Age of menarche, reaction to menarche, regularity of periods, any
abnormalities, emotional disturbances in relation to menstrual cycle.
VIII. Sexual history:
Age of onset of puberty, level of knowledge regarding sex and mode of
getting the same, masturbation, anxiety related to sexual practices,
homosexuals and heterosexual inclinations and experiences, extra marital
relationships.
IX. Marital history:
 Age at the time of marriage, arranged by elders or self, mutual consent if
partners, age , education, occupation, health and personality of the partner.
Quality of marital relationship, any separation or divorce, number of children
their ages and health statuses.
X. Substance abuse:
Smoking, alcohol, drinking pattern, abuse of other substances like cannabis
opiates and barbiturates.

VI. PREMORBID HISTORY:

Description of the personality prior to the onset of illness.
Especially important in case of a neurosis or affective disorder.
1) Social relations
To family, friend, groups, societies, clubs, work and workmates.
2) Intellectual activities, hobbies, interests
Books, play, pictures, memory, observation, judgement.
3) Mood
Bright, cheerful, despondent, worrying or placid, strung up or calm
and relaxed, optimistic or pessimistic, self-depreciative or satisfied.
4) Character
i. Attitude to work and responsibility:
welcomes or worried by responsibility.
Makes decisions easily or with difficulty
Hazardous and slapdash or methodical and meticulous
rigid or flexible
cautious, foresight and given to checking or impulsive slip
hold.
Persevering and determined or easily bored and discouraged.
ii. Interpersonal relationships:
Self confident or shy and timid
Insensitive or touchy to criticism
Trusting or suspicious and jealous
Emotionally controlled or quick temper and irritable
Tactful or out spoken
Enjoys or shuns self display
Quiet and restrained or expressive and demonstrative in
speech and gesture
Interests and enthusiasms sustained or evanescent
Tolerant or intolerant towards others.
Adaptable or inadaptable.
iii. Standards in moral, religious, social and health matters.
Level of aspiration low or high
Perfectionist and self-critical or complacent and self-approving
in relation to own behaviour and achievement.
Steadfast in face of difficulties or intolerant of frustrations.
 Self and egoistical or unselfish and altruistic
Given too much or too little concern about ones health.
iv. Energy, initiative
Energetic or sluggish
Output sustained or fitful
Fatigability
Any regular or irregular fluctuations in energy or output.
5) Fantasy life:
Frequency and content of day dreaming.
6) Habits:
Eating, alcohol and tobacco consumption, self-medication
Specify amount consumed recently and earlier, sleeping, excretory
functions.
 MENTAL STATUS EXAMINATION

MSE has to be repeated several times during the course of the illness to the
evolution of symptom, effectiveness of treatment etc.

1. General behaviour
Observation of ward staff and observation of the examiner.
The way of spending the day- eating, sleeping
Cleanliness in general-self care, hair, dress
Behaviour towards other patients , nurse , doctors
Looking healthy or not?
Conscious/stupors/comatose
In touch with surroundings?
Relaxed/tensed/ restless?
Slow/ hesitant?
Abnormal response to external events
Attention can be held or diverted?
Cooperative?
Adequate rapport can be established?
Behaviour suggests that he is dis oriented
Presence of tics / mannerisms/ catatonic phenomenon/ restlessness/ winging
of hands(aimless, purposeless activity)

2. Psychomotor activity
Note PMA is increased/ decreased/ normal

3. Speech
Spontaneous or only in response to questions?
Amount of speech little or excessive
High / low tone
Tempo fast/slow
Reaction time inc/ decreased
Is the prosody of speech maintained
Is it relevant and coherent

4. Thought
 Form: presence of formal thought disorder
 Stream : flight of ideas/ retardation of thinking/ circumstantiality/
perseveration/thought blocking/
 Possession: obsessions and compulsions
Obsessions-ideas, doubts, imaginary impulses, phobias
 Compulsory acts-checking, counting, washing.
Controlling compulsions or yielding compulsions
Thought alienation
 Content: over valued ideas and delusions
Delusions single or multiple
Type of delusions- grandiose, persecutory, nihilistic etc
Exact content of delusions
Whether fleeting or fixed
Well systematised or poorly
Mood congruent or not
Enquire about worries, pre occupations, hypochondriacal somatic
symptoms
Depressive ideation, ideas of worthlessness, guilt, hopelessness,
suicidal ideas

5. Mood
Assess subjective report and objective evaluation.
Assess both longitudinal (mood) and sectional (affect)
Quality of emotion-happiness/ sadness etc
Intensity of emotional expression-flat blunt normal
Range of affective responses-full, restricted
Mobility, reactive-change in motion in relation to environmental factors.
Diurnal variations
Congruity in relation to thought process
Appropriateness in relation to situations
Lability- rapid and extreme changes in emotions
6. Perception
Hallucinations
 Modality-vision, hearing, smell, touch, taste, pain, deep sensations,
vestibular sensations and sense of presence
 Special varities- functional, reflex, extra campine synaesthesia and
autoscopy
 Detailed description of hallucination
 Auditory hallucination- verbal or non verbal
o Continuous or intermittent
o Single voice or multiple voice
o Familiar or unfamiliar
o First person/ second/ third person
o Pleasant or unpleasant
o If unpleasant-commanding, abusive or
threatening
 o A relationship with hallucinations
o Whether mood congruent
o Distinguish hallucinations from
imagery and pseudo hallucination

 Illusions
 Heightened perceptions
 Dulled perceptions
 Depersonalization, derealization, experiences
 Disturbances in the perception of time

7.Cognitive functions

a) Attention and Concentration

Digit span test-forward and backward

Forward:
5-7-3 4-1-7
5-3-8-7 6-1-5-8
1-6-4-9-5 2-9-7-6-3
3-4-1-7-9-6 6-1-5-8-3-9
7-2-5-9-4-8-3 4-7-1-5-3-8-6
4-7-2-9-1-6-8-5 9-3-5-8-3-1-7-4
Ask the patient to listen carefully and repeat them in the same order
after the examiner finishes.
Read the digits at the rate of one per second to the patient
The same digit should not be presented more than once.
Note whether the immediate response of the patient is correct or
incorrect, if the patient cannot repeat a second trial of the same
number of digits is given and credits is given if the response is correct.
The digit span is the highest number of digits repeated correctly
Backward:
Ask the patient to listen to the digits carefully and repeat them in a
reverse order. The same digits should not be used as per the forward
test. Digit should not be repeated in the series presented, the digit
backward score is the highest number of digits correctly recalled
backward after a maximum of two trials. Increasingly difficulty tests
are presented. the examiner instructs the patient with an example of
how to perform a task, note the responses verbatim and note the
time taken in seconds.
 TASK CORRECT RESPONSE N TIME
20-1 20 to 0 in 15 sec
40-3 40,37,34 etc in 60s
100-7 100,93,86 etc

Days or months repeated in forward or backward manner.

b) Orientation
Three aspects are described to time place and person

 Time:
Approximately what time of the day is it?
(if patient is unable to reply, more specific question maybe
asked)
Is it morning/evening/afternoon/night?
( in addition further questions may be asked to asses time)
Approximately how long is it since you had your
breakfast/lunch/tea
Approx. how long have I been talking to you?
What is the date and day today?
 Place:
What place is this?
(if unable to answer a specific question is asked)
Is this a school/hospital/office etc?
(If patient says it is hospital, details may be asked )

 Person:
Orientation to self is tested by asking identity if the patient.
Enquire about the identity of the patients relatives and family
members.

c) Memory:
Assessment includes immediate, recent and remote memory

 Immediate- digit span test

 Recent-
1.address test -an address containing about 4-5 facts not
known to the patient is slowly read to the patient, after
instructing him to attend to the examiner he is engaged in the
 conversation ( to avoid rehearsal ) and the response is noted
verbatim.
2. asking the patient to recall events in the past 24
hours
Responses given by the patient or cross checked from
the reliable source.

 Remote – information on life events

 DOB/age
 no of children
 name and no of family members
 time since marriage and death of
any family members
 year of completing education
d) Intelligence :
It includes areas of general information, comprehensive, arithmetic abstraction

 General information-
o Literacy, age, occupation
 For literates- names of PM,CM, capitals of countries,
current events
 For illiterates- seasons, crops and fruits grown in
particular seasons. Prices of food grain / food items.

 Comprehension-
o The ability to understand questions asked during an interview
is 1 index.
o Questions of increasing difficulty may be asked.
 What will you do when you feel cold?
 What will you do if it rains, when you start for work?
 What will you do when you miss the bus, when you are
on journey
 Why should you be away from bad company?
 Arithmetic:
o Following questions may be asked with increasing time units
 How much is 4 rupees plus 5 rupees?
 I borrowed 6 rupees from a friend and returned 2
rupees, how much do I still owe to him?
 If a man buys cloth for 12 rupees, and gives a shop
keeper 20 rupees, how much change would he get
back?
  How many pencils can you buy for 2 rupees if 1 pencil
cost quarter of a rupee or 25 paisa?
 Time limit : first 3 15 sec and fourth is 30 sec.
 Abstraction:
o Tested by similarities , differences and proverbs.

1.Differences
 being an easy task is always presented before
similarities.
 Differences a pair of words are presented to the
patient and asked to tell what why they are different
from each other .
 Stone – potato (not edible -edible / hard-soft)
 Fly-butterfly (small-large/not colourful-colourful)
 Cinema-radio (audio visual-audio)
 Iron-silver (heavy-light/ dull-bright)

2. Similarity:
 A pair of words are given and patient is asked to tell, in
what way are they alike?
 What is common between them, what is the similarity
between them.
 Orange-banana (fruits)
 Dog-lion (animals)
 Eye-ear (sense organs)
 North-west (directions)
 Table-chair (furniture)
3. Proverbs
 Whether he knows what a proverb is?
 Eg of a proverb and what it means
 When the patient has the concept of a proverb,
the following may be asked
o Slow and steady wins the race
o A barking dog never bites
o As you sow, so shall you reap
o All that glitters is not gold
o Where there is a will there is a way
 The response of the patient is to be noted
verbatim and the answer is to be judged
whether correct or incorrect.
e) Judgement

 Three areas personal, social, test

o Personal judgement is assessed by enquiries about the patients future
plans
o Social judgement is assessed by observing behaviour in social
situations
o Test judgement - 2 problems are presented in a manner in which he
can comprehend.
 Fire – in the house in which you are catches fire, what is the
first you will do?
 Try to put it off with water
 Better problem- when you are walking on the road you see a
stamped and sealed enveloped with an address on it, which
someone had dropped, what will you do?
 Post it in a letter box or give it to the postman
f) Insight:

 Test the level of awareness of his illness’

o Absent- patient thinks that he is not at all ill.
o Partial -patient recognizes that he is ill but gives explanation in
physical terms
o Present-he fully realises his emotional nature of his illness and cause
of his symptoms.
SUMMARY
The purpose of a summary is to provide a concise description of all the important aspects of
the case to enable others unfamiliar with the patient to grasp the essential features of the
problem. The summary should be presented same format as described above

FORMULATION
This is the student’s own assessment of the case rather than the statement of the facts. Its
length, limit and emphasis will vary considerably from one patient to another. It should
always include a discussion of the etiological factors which seems important. A plan of
management and estimate of the prognosis regardless of the uncertainty or complexity of
the case, a provisional diagnosis should always be specified.
EXAMINATION:
A complete physical examination is mandatory for each patient.
INVESTIGATIONS, TREATMENT AND FOLLOWUP:
Biochemical, radiological and psychometric investigations should be carried out where ever
appropriate. All aspects of management, physical, psychological and social interventions
should be included in the treatment, though the relative emphasis may differ from case to
case, progress notes should be systematically recorded.
FINAL FORMULATION
This is a revision of the initial formulation drawn up at the time of discharge. It should
specify any discrepancies of opinion and should state in the views of the consultant clearly.
It should be written in the light of the pupil response to imitate and other information
becoming available since the time of admission. Its length and layout will vary considerably
but it should always include a final diagnosis amplifying comments and an estimate of the
prognosis.