HISTORY COLLECTION
I. Client identification data/client profile
Name
Age
Sex
Ward
IP/OP No
DOA
Education
Occupation
Income /family income (Rs)
Marital status
Religion
Mother tongue
Language known
Address
Referred from
Mode of admission
Informant
Reliability
Diagnosis
II. Reason for admission with duration
According to client: Why you came here?
- I have a problem
: Mr. D said that he is not getting sleep
- How many days-3 days
According to informant : What is the reason for admission
- Mr. J’s father said that he has no sleep; he is spending more money
how long?
III. Biological functions and Habits
Appetite: You had food? No why?
- Somebody is added poison in food
If no change – Normal
Sleep pattern: Did you slept? No
When did you go to bed? 11’clock
When you got up? 6’ clock
Elimination pattern
(Bladder & Bowel pattern) : Bowel and bladder pattern is regular
Habits (smoking / substance use): If no Mr. J does not have the
substance abuse
IV. History of presenting illness :
C: Write the details of present episode
(After 3-4 days of admission from client, Patient informant)
- Mr. J 22 yrs old male got admitted on 22/10/19 with the
complaints of insomnia.
Since 3 days, Anorexia 1 month due to the death of father and
diagnosed as anxiety disorder
From the day of admission following ways are given in medical
ECT, Recreational therapy, Investigation
V. Past psychiatric history (if yes) :
Write episode wise
Reason for admission with diagnosis (Type of admission)
In May 2019 Mr- If any stoppage.
Facility name with date and duration of admission
Treatment detail – drug/ECT/psychosocial/therapies
Mention the side effects of drug if so
Mode of discharge and condition on discharge mood cycle
(BPAD)
In 2 jan 2019
If BPAD Draw
VI. Family history
3 generation genogram with appropriate key
Consanguinity: Yes/No ,if yes specify
H/O illness in the family (Mental illness /physical illness
: Yes/No, if yes-specify
H/O ran out (knowingly gone), last person, suicidal attempts
committed suicide, substance related disorders
: Yes/No, if yes-specify
Stress in the family : Yes/No: If yes –specify
Inter relationship in the family: satisfactory/ unsatisfactory (if un
satisfactory –specify)
VII. Medical and surgical history:
If yes, write in detail
VIII. Personal History
A. Perinatal history
Antenatal period: Uneventful /Eventful (specify)
Nature (or) mode of delivery: FTND, vacuum, LSCS, IUGR,
preterm.
Place of delivery: Home (or) Hospital
Intranasal Complications in mother: Yes/No (if yes: specify
(Delivery pain started till the delivery)
Fuetal complication: Yes/no, if yes –specify (aspiration,
asphyxia)
Birth cry:
Birth weight:
Postnatal complications: Yes/no, if yes: specify
B. Childhood History
Brought up by: parents or grandparents
Immunized us per schedule: Yes/no ,If yes specify
(Any bacterial viral infection produces disease)
Growth physiological and development (psychological)
Normal /delayed, if delayed specify(emotional or
intellectual)
Neurotic traits or behavioral problems: Nail biting /thump
sucking/head banging ,breath holding/body rocking/
Temper tantrum/stealing/telling lies
Childhood medical illness (if yes ,specify)-Major illness
cancer ,congenital anomalities
Childhood psychiatric illness (If yes specify)-
Anxiety ,Enuresis ,Encopresis
C. Educational History
Age of beginning formal education : Early or late
Age of completing education : Completed education 10 yr 10th std
Grade reached : Qualification
Scholastic performance: satisfactory/ unsatisfactory
(If unsatisfactory specify: How the child is academically poor or good
in study)
Co-curricular and extracurricular activities: Any compaction sports, arts
etc.
Relationship teachers : satisfactory/ unsatisfactory (If unsatisfactory
specify)
Relationship with peer groups :Satisfactory / unsatisfactory
(If unsatisfactory specify- substance abuse)
School related problems :school refusal/school phobia (excess absent of
school)/truancy/learning difficulties /school dropout (why dropout)
Failure in exams : yes or no
D. Occupational History
Age of starting job :Early /late
Nature of job :what they are working
Change of job: yes or no ,if yes – How many times and reason for
change in the job
Present job:(If there is no change Once only write)
Satisfaction with the job: satisfied (money)/unsatisfied (If
unsatisfied specify :R/s with authority ,R/s with co-
workers ,subordinate ,etc)
Relationship with higher authority : satisfactory/ unsatisfactory
(If unsatisfactory specify)
Relationship with coworkers: satisfactory/ unsatisfactory
(If unsatisfied specify)
Relationship with subordinate: satisfactory/ unsatisfactory
(If unsatisfied specify)
Stress in the job: Yes/No ,If yes –specify
E. Menstrual History
Age of menarche:
Menstrual cycle with duration: 28 days of cycle/3-4 days
Menstrual regularity: Regular/irregular
Menstrual abnormalities: Yes/No ,If yes –specify
(Amenorrhea, menorrhagia )
Premenstrual symptoms: Yes/No if yes-specify
(Mood changes, any mood swing, any menstrual distress only)
Age of menopause: Not attained nothing to be write
Post menopausal symptoms : yes /No, If yes specify
F. Sexual History
Knowledge about the sex
Exposure : Married /Unmarried
Sexual deviation: Yes/No ,if yes-specify
G.Marital History
Marital genogram with appropriate key
Age of patient at the time of marriage :
Age of spouse at the time of marriage:
Nature of marriage: Love/arrange
Willingness for marriage :yes/no ,if no specify
Support from family :yes/No ,if No specify
Consanguinity :Yes/No ,if yes specify
Duration of marriage
Sexual relationship :satisfactory/unsatisfactory
Interpersonal relationship: satisfactory/unsatisfactory
(If unsatisfactory specify)
H.Obstetrical History
Obstetrical score:GPL2A1D1
G=Abortion will not come under Para
L & D will come under Para
Mode of delivery:
Perinatal complication :yes/No ,If yes specify
Mental. Status during perinatal period :Mentally comfortable
Premorbid personality (Morbid-illness ,pre-before)
Attitude toward self did you have like before illness?
What was the attitude yours If before illness?
Attitude towards other: +ve attitude
Use of leisure time: used to have good other
Reaction to stressful life events: when you get any problem how
will you adjust with that?
(I will go & share with friend/ I will sit & cry /I will be alone)
Moral attitude and religious beliefs: whether you have belief in
God?
Predominant mood:
- Interactive ,+ve active
(Optimistic/extrovert)
- Negative inactive
(Pessimistic/introvert)
