Case History Format

I. Identification Data

Name:
Age:
Sex:
Marital Status:
Education:
Occupation:
Income:
Residential/Office Address
Religion
Socio-economic Background

II. Informants
The informants’ identification data should be recorded along with their relationship to the
patient, whether they stay with the patient or not, and the duration of stay together.

The reliability of the information provided by the informants should be assessed on the
following parameters:
1. Relationship with patient,
2. Intellectual and observational ability,
3. Familiarity with the patient and length of stay with the patient, and
4. Degree of concern regarding the patient.

Five parameters should be assessed. Consistency, Coherence, Chronological information,

Closeness with patient, Concern for patient (5 Cs).

Source of referral should also be mentioned

III. Presenting/Chief Complaints
Both the patient’s and the informant’s version should be recorded, if relevant. The
complaints should be recorded verbatim. (Record the complaints in a chronological
order.)

IV. History of Present Illness

The symptoms of the illness, from the earliest time. at which a change was noticed (the
onset) until the present time, should be narrated chronologically. Presenting complaints
should be expanded. Any changes in the pt. Habits, behavior, interests, relationships or
physical health.
What are the symptoms? How severe? For how long? Why is the patient seeking help
now? What triggered the current set of symptoms?
Presence/Abscence of stressors.
Any legal case
Any disturbance in sleep, appetite, sexual functioning. Social and occupational life.
The specific nature of the disturbance and the degree of disability should be recorded.

Lastly, certain historical details must be routinely enquired into, to rule out an organic
etiology. These include: history of trauma, fever, headache, vomiting, confusion,
disorientation, memory disturbance, history of physical illness like hypertension/diabetes
and history of substance abuse, while these details are important regardless of the nature
of presentation, they are particularly important in the elderly.

Onset: Note if the onset of the symptoms is abrupt (onset in 48 hrs), acute (i.e.,
developing within
few hours – 2 weeks, sub-acute (few weeks) or insidious (few weeks to few months).
Course of the illness: The course of an illness can be episodic (discrete symptomatic
periods with
intervening period of normalcy, continuous or fluctuating (Periodic exacerbations in a
continuous
 illness).
A life chart helps.

Elicit the 4 Ps- Predisposing, Precipitating, Perpetuation and protective factors.

V. Past Psychiatric History

 Any past history of having received any psychotropic medication, alcohol and drug abuse
or dependence, and psychiatric hospitalization should be enquired.
WHen? How long ago? Duration, How severe, nature of the symptoms, frequency of the
episodes.
Past treatment: Pharmacological, behavioral, psychotherapy: individual, group, couple,
family.
Hospitalization/ Outpatient/ Voluntary treatment or involuntary/ OT
WHat was the trigger to seek treatment?
Why discontinued? Response to previous treatment/meds?
Previous diagnosis? Made by whom?
Past suicidal ideation, intent, plan and attempts, NSSI- how, when , why
Violence or homicidal History

VI. Past Medical History

Any major medical conditions, past surgeries, ongoing treatments, seizures, head injury,
any pain. Effect of the current medications, and how they are managing the medical
symptoms, allergies- nature, extent, treatment.

VII. Family History

The family history usually includes the ‘family of origin’ (i.e. the patient’s parents,
siblings, grandpar ents, uncles, etc.). Draw a three generation genogram with standard
symbols.
Give a description of the individual family members (parents and siblings). The
description should include information as to whether they are living or dead, age (or age
of death), education, occupation, marital status, personality and relationship with the
patient.
Family history of similar or other psychiatric ill nesses, major medical illnesses, alcohol
or drug dependence and suicide (and suicidal attempts) should be recorded.
 Current social situation: Home circumstances, per capita income, socioeconomic status,
leader of the family (nominal as well as functional) and current attitudes of family
members towards the patient’s illness should be noted.
The communication patterns in the family, range of affectivity, cultural and religious
values, and social support system, should be enquired about, where relevant.

VIII. Personal and Social History

1) Pre natal, perinatal, post-natal history:
Difficulties in pregnancy (particularly in the first three months of gestation) such
as any febrile illness, medications, drugs and/or alcohol use; abdominal trauma,
any physical or psychiatric illness should be asked. was the birth at full term?
Whether delivered in hospital or at home? Any complications during delivery?
Any Physical illnesses in the postnatal period? Ascertain whether milestones of
development were normal or delayed. Any perinatal complications (cyanosis,
convulsions, jaundice), APGAR score (if available), birth cry (immediate or
delayed), any birth defects, and any prematurity. Especially important to elicit this
in young children.

2) Childhood History:
Whether the patient was brought up by mother or someone else, breastfeeding,
weaning and any history suggestive of maternal deprivation should be asked. The
age of passing each important developmental milestone should be noted. The age
and ease of toilet training should be asked.
stuttering, stammering, tics, enuresis, encopresis, night terrors, thumb sucking,
nail biting, head banging, body rocking, morbid fears or phobias, somnambulism,
temper tantrums, and food fads.
Look for conduct disturbances in the form of frequent fights, truancy, stealing,
lying and gang activities. Also enquire about relationships with parents, siblings
and peers.
The questions to be asked include, what games were played at what stage, with
whom and where. Rela tionships with peers, particularly the oppo site sex, should
 be recorded. The evaluation of play history is obviously more important in the
younger patients.
Record physical illnesses suffered in childhood. Enquire specifically regarding
epilepsy, meningitis and encephalitis.

3) Educational History
The age of beginning and finishing formal education, academic achievements and
relationships with peers and teachers, should be asked. Any school phobia,
non-attendance, truancy, any learning diffi culties and reasons for termi nation of
studies (if occurs prema turely) should be noted

4) Occupational History
The age at starting work; jobs held in chronological order; reasons for changes;
job satisfactions; ambitions; relationships with authorities, peers and subordinates;
present income; and whether the job is appropriate to the educational and family
background, should be asked.

5) Menstrual History
The regularity and duration of menses, the length of each cycle, any
abnormalities, the last menstrual period, the number of children born, and
termination of pregnancy (if any) should be asked for. dysmenorrhea,
menorrhagia/oligo menorrhea; emotional disturbances in relation to menstrual
cycle.

6) Sexual History and Marital History

The age at menarche, and reaction to menarche (in females), the age at
appearance of secondary sexual characteristics (in both females and males),
nocturnal emissions (in males), masturbation and any anxiety related to changes
in puberty should be asked.
 Sexual information, how acquired and of what kind; masturbation (fantasy and
activity); sex play, if any; adolescent sexual activity; pre marital and extramarital
sexual relationships, if any; sexual practices (normal and abnormal); and any
gender identity disorder, are the areas to be enquired about.
The duration of marriage(s) and/or relationship(s); time known the partner before
marriage; marriage arranged by parents with or without consent, or by self-choice
with or without parental consent; number of marriages, divorces or separations;
role in marriage; interpersonal and sexual relations; contra ceptive measures used;
sexual satisfaction; mode and frequency of sexual intercourse; and psychosexual
dysfunction (if any) should be asked.

7) Substance use:
Use and abuse of alcohol, tobacco and drugs; Enquire about smoking and
drinking pattern and abuse of other drug like cannabis, opiates etc.

XI. Premorbid Personality

It is important to elicit details regarding the personality of the individual (temperament, if the age
is less than 16 years).

1. Interpersonal relationship: Interpersonal relationships with family members, friends, and work
colleagues; introverted/extroverted; ease of making and maintaining social relationships.

2. Use of leisure time: Hobbies; interests; intellectual activities; critical faculty; energetic/
sedentary.

3. Predominant mood: Optimistic/pessimistic; stable/prone to anxiety; cheerful/despondent;

reaction to stressful life events.

4. a. Attitude to Work and responsibility: welcomes or is worried by responsibility, makes

decisions easily or with difficulty; haphazard and slapdash or methodical and
meticulous; rigid or flexible; cautious, fore-sightful and given to checking or impulsive
and slipshod; persevering and determined or easily bored or discouraged.
b. 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; quiet
and restrained or expressive and demonstrative in speech and gesture, interest and
enthusiasms sustained or evanescent, tolerant or intolerant of others; adaptable or
rigid.

6. Religious beliefs and moral attitudes: Religious beliefs; tolerance of others’ standards and
beliefs; conscience; altruism.

7. Fantasy life: Sexual and nonsexual fantasies; daydreaming-frequency and content; recurrent or
favourite daydreams; dreams.

8. Habits: Food fads; alcohol; tobacco; drugs; sleep

MSE

I. General Appearance and Behaviour:

Physique and body habitus (build) and physical appearance (approximate height, weight,
and appearance),
Well kempt/kempt/overly made up/unkempt and untidy/sickly/perplexed
Looks comfortable/uncomfortable,
Physical health,
Dress: Appropriate/Shabby/Inappropriate
Gait
Posture: Stooped/Relaxed/Stiff/Shaky/Slouched/Crouching/Erect/Posturing/Bizzare
mannerisms/Catatonia
Grooming,
 Hygiene,
Self-care,
Effeminate/masculine
Distinguishing features: Scars, tattoos, disfigurations
Eye contact: Maintained/Absent/ Partial
Attitude towards examiner:
Cooperation/guardedness/evasiveness/hostility/defensive/haughtiness/disinhibited,
disinterested/seductive/evasive
Appears interested/disinterested/apathetic,
Any ingratiating behavior,
Perplexity
Behaviour towards other patients, doctors and nursing staff
Does the patient look ill? Note whether the patient is fully conscious, stuporose or
comatose; is he in touch with surroundings?
How does he respond to various requirements and situations? Are there abnormal
responses to external events?
Can his attention be held or diverted?
Tics/ Mannerisms.
Comprehension: Intact/impaired (partially/fully)
Rapport: Easily Established/ Difficult to establish

II. Psychomotor Behaviour

Increased/decreased,
Excitement/stupor,
Abnormal involuntary movements (AIMs) such as tics, tremors, akathisia,
Restlessness/ill at ease,
Catatonic signs (mannerisms, stereotypies, posturing, waxy flexibility, negativism, ambi
ten dency, automatic obedience, stupor, echo praxia, psychological pillow, forced
grasping)
Conversion and dissociative signs (pseudo seizures, possession states),
Social withdrawal,
 Autism,
Compulsive acts,
rituals or habits (for example, nail biting),
Reaction time

Retardation/Hyperactivity/Preoccupied/Mannerisms/Restless/Stereotyped
behavior/Grimace/Awkward/Destructive/Self Injurious/silly
smiling/tics/aggressive/rigidity/touching the examiner/ gestures/ hallucinatory behavior (
Smiling or crying without reason, Muttering or talking to self (non-social speech). Odd
gesturing in response to auditory or visual hallucinations)/ waxy flexibility

III. Speech
Rate and quantity of speech
\Whether speech is present or absent (mutism),
If present, whether it is spontaneous,
whether productivity is increased or decreased,
Rate is rapid or slow (its appropriateness),
Pressure of speech or poverty of speech.
Volume and tone of speech Increased/decreased (its appropriateness),
Low/high/normal pitch
Flow and rhythm of speech Smooth/hesitant, Blocking (sudden), Dysprosody,
Stuttering/Stammering/Cluttering,
Any accent

Describe under these headings; relevance, coherence, volume, tone, tempo, reaction time

IV. Mood and Affect

This should be assessed by both subjective report and objective evaluation; assessment
should be both longitudinal (mood) and cross-sectional (affect). Description should be
given regarding the following components; the quality of affect (happiness, sadness,
anxiety etc.), the intensity or depth of emotional experience, the range of affective
 responses, reactivity (changes in emotion in relation to environmental factors), diurnal
variation, congruity (in relation to thought processes) and appropriateness (in relation to
situations). Note any evidence of lability (rapid and extreme changes in emotion).
Dysphoric/ Depressed/anxious/irritable/euthymic/elevated/exalted/euphoric/estatic
V. Thought
Examine thought processes with respect to-

Form and Stream are overlapping:

Presence of formal thought disorder
‘Formal thought disorder’: a synonym for the disorders of conceptual or
abstract thinking which occurs in schizophrenia and coarse brain disease.
FTD can be divided into 2 subgroups:
Negative FTD: the pt. has lost his previous ability to think, but does
not produce any unusual concepts.
Positive FTD: The pt. produces false concepts by blending together
incongruous elements.
Circumstantiality, Tangentiality, Clang associations, Derailment, Neologism,
Perseveration, Thought Blocking

Stream: Flight of ideas, retardation of thinking, circumstantially, perseveration, thought

blocking

Possessions: Obsessions and compulsions, thought alienation. With respect to obsession,

elicit their nature-ideas, doubts, imagery, impulses and phobias. Similarly clarify the
nature of compulsive acts checking, counting or washing; Are these `controlling’
compulsions or yielding compulsions?

Content: Look for the presence of overvalued ideas and delusions before making an
inference, a detailed description of the phenomenon must be given. Note whether the
delusion is single or there are multiple delusions, the type of delusion (grandiose,
persecutory, nihilistic etc.), the exact content of the delusion, whether they are fleeting or
 fixed, whether they are well systematized or poorly systematized and whether they are
mood congruent or not; Enquire about worries and preoccupations, hypochondriacal and
somatic symptoms. Depressive ideation, ideas of worthlessness, guilt, hopelessness and
suicidal ideas must be enquired and recorded.

VI. Perceptual Disturbances:

Record the presence of illusions and hallucinations.
Enquiry should be made into the following: modalities, vision, hearing, smell, taste, pain
and deep sensations vestibular sensations and sense of presence;
record also the presence of special varieties of hallucinations like functional
hallucinations, reflex hallucinations, extra-campine hallucinations, synesthesia and
autoscopy.
Detailed descriptions of the actual experience should be obtained, for example, with
respect to auditory hallucination enquiry whether the hallucinations are verbal or non
verbal, continuous or intermittent, single voice or multiple voices; familiar or unfamiliar
voice; first person, second person or third person; pleasant or unpleasant, if unpleasant,
whether commanding, abusive or threatening; response to hallucinations; whether mood
congruent.
Distinguish hallucinations from imagery and pseudo-hallucinations.
Other perceptual disturbances that must be enquired into include heightened perception,
dulled perception, depersonalization/derealization experiences.

Illusions and misinterpretations: Whether visual, auditory, or in other sensory fields;

whether occur in clear consciousness or not; whether any steps taken to check the reality
of distorted perceptions.
Depersonalisation/derealisation: Depersonalisation and derealisation are abnormalities in
the perception of a person’s reality and are often described as ‘as-if’ phenomena.
Somatic passivity phenomenon: Somatic passivity is the presence of strange sensations
described by the patient as being imposed on the body by ‘some external agency’, with
the patient being a passive recipient.
 Others: Autoscopy, abnormal vestibular sensations, sense of presence should be noted
here
VII. Cognition
From Nimhans Proforma
VIII. Judgment
Judgment is the ability to assess a situation correctly and act appropriately within that
situation. Both social and test judgment are assessed.
i. Social judgment is observed during the hospital stay and during the interview session. It
includes an evaluation of ‘personal judgment’.
ii. Test judgment is assessed by asking the patient what he would do in certain test
situations, such as ‘a house on fire’, or ‘a man lying on the road’, or ‘a sealed, stamped,
addressed envelope lying on a street’.
Judgment is rated as Good/Intact/Normal or Poor/ Impaired/Abnormal
IX. Insight
Insight is rated on a 6-point scale from one to six.
1. Complete denial of illness.
2. Slight awareness of being sick and needing help, but denying it at the same time.
3. Awareness of being sick, but it is attributed to external or physical factors.
4. Awareness of being sick, due to something unknown in self.
5. Intellectual Insight: Awareness of being ill and that the symptoms/failures in social
adjustment are due to own particular irrational feelings/thoughts; yet does not apply this
knowledge to the current/future experiences.
6. True Emotional Insight: It is different from intellec tual insight in that the awareness
leads to signifi cant basic changes in the future behaviour.