Psychiatric History Performa
Name: ____________________________________ s/d/o _______________________________
Age: ________
Gender: ______________
Education: _________________________
Marital status: ____________________
Occupation: ____________________________
Informer: __________________
Presenting complaints
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Past psychiatric history
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Past Medical History
_____________________________________________________________________________________
_____________________________________________________________________________________
Medication
1. ______________________
2. ______________________
3. ______________________
4. ______________________
5. ______________________
Family history
_____________________________________________________________________________________
_____________________________________________________________________________________
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Family psychiatric history
_____________________________________________________________________________________
_____________________________________________________________________________________
Personal history
Birth: Normal / c- section
Early life: Normal / Any history if yes then report ____________________
School & Qualifications: Good / not good / Average
Education: _______________
Employment: ______________________
Psychosexual History: Ask about loss of libido or dislike of sexual contact. If
report then write ____________________________
Forensic History: yes / no If yes then write
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Substance Abuse: Reported / not reported
Hash Ice Marijuana opium Alcohol
Initial dosage (in-gram) ____________ now quantity (in-gram) _______________
Duration __________ Frequency (how many dosages per day) ________________
Premorbid personality
Mood: mood was happy or not.
______________________________ ____________________________________
Social Relationship: how’s relationship with other people and family members.
___________________________________________________________________
Moral Values: how’s believe in moral values like, offer prayers, kind person,
gratitude etc.
___________________________________________________________________
Smoking: smoking history if any quantity, and duration of smoking.
Yes / Not If yes then
Quantity: ____________ Duration: ________________
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Attitude: ask about behavior towards the people, person and events
_______________________________________________________
Stress Reaction: psychologist should ask about stress reaction in particular
situation what’s the emotions like, silent, abusive, weeping and aggressive (verbal
and physical).
________________________________________________________
Hobbies: ask about hobbies because, it will help you during treatment.
_________________________________________________________
Abnormal Traits: any abnormal traits ask them.
__________________________________________________________
Others: at the end ask any other specific event things which you want to know
about your clients.
___________________________________________________________________
___________________________________________________________________
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