MENTAL HEALTH NURSING

HISTORY COLLECTION FORMAT

I. IDENTIFICATION DATA

Name:

Age:

Sex:

Address:

Education:

Occupation:

Income:

Marital status:

Religion:

Informant:

Information: Relevant / not relevant, adequate / not adequate

II. PRESENTING CHIEF COMPLAINTS

With duration in chronological order

 According to the client

 According to the informants

III. HISTORY OF PRSENT ILLNESS

Duration (days / weeks / months / years)

Mode of onset : Abrupt / acute / subacute / insidious

(<48hrs / <1wk / 1-2wks / within a few weeks)

Course : Continuous / episodic / fluctuating / deteriorating / improving /unclear

Intensity : Same / increasing / decreasing

Precipitating factor : Yes / no, if yes explain

Description of present illness (chronological description of abnormal behaviour, associated
problems like suicide, homicide, disruptive behaviour, thought content, speech, mod states,
abnormal perception, biological functioning, social functioning, occupational functioning,
changes in ADLs)

IV. TREATMENT HISTORY

Drugs (name of the drug, dose, route, side effects, if any)

ECT:

Psychotherapy:

Family therapy:

Rehabilitation:

V. PAST PSYCHIATRIC AND MEDICAL HISTORY

Number of previous episodes / hospitalization (psychiatric) with onset and course:

Complete or incomplete remission:

Duration of each episode:

Treatment details and its side effects if any:

Treatment outcome:

Details of any precipitating factors if present:

Substance use details:

Surgical procedures / accidents / head injury / convulsion / unconsciousness / DM / HTN /

CAD / venereal disease / HIV positivity / any other

VI. FAMILY HISTORY

Description (describe each family member briefly: age, education, occupation, health status,
relationship with the patient, age at death, mode of death)

Genogram

Socio economic status

VII.PERSONAL HISTORY

A.Perinatal History
Antenatal period : Maternal infections / exposure to radiation / any other

Check ups, regular visits

Any complication.

Intranatal period : Type of delivery – Normal / instrumental / cesearian

Any complication

Birth : Full term / premature / postmature

Birth cry : Immediate / delayed

Birth defects : Yes or no, if yes, specify

Postnatal complications : Cyanosis / convulsion / jaundice / neonatal infections / any other

B. Childhood History

Primary caregiver :

Feeding : Breastfed / artificial mode of feeding

Age of weaning :

Developmental milestones : Normal / delayed

Behaviour and emotional problems: Thumb sucking / excessive temper tantrums / stuttering /
head banging / body rocking / nail biting / pica eating / enuresis / morbid fear / night terrors /
somnambulism

Illness during childhood : Specifically for CNS infections / epilepsy / neurotic disorders /
malnutrition

C. Educational History

Age at beginning of formal education:

Academic performance:

(Specifically look for learning disability and attention deficit disorders)

Extracurricular achievements, if any:

Relationship with peers and teachers:

School phobia: yes / no

Look for conduct disorder, for example truancy / stealing: yes / no

Reason for termination of studies:

D. Play History

Games played (at what stage and with whom):

Relationship with playmates:

E. Emotional problems during Adolescence

Running away from home / delinquency / smoking / drug taking / any other (specify)

F. Puberty

Age at appearance of secondary sexual characteristics:

Anxiety related to puberty changes:

Age at menarche:

Reaction to menarche:

Regularity of cycle, duration of flow:

Abnormalities, if any (menorrhagia, dysmenorrhea etc)

G. Obstetrical History

LMP:

Number of children:

Any abnormalities associated with pregnancy, delivery, puerperium:

Termination of pregnancy, if any:

Menopause (including any associated problems):

H. Occupational History

Age at starting work:

Jobs held in chronological order:

Reason for changes:

Current job satisfaction:

(Including relationship with authorities, colleagues, subordinates)

Whether job is appropriate to client’s background:

I. Sexual History

Type of marriage : Self choice / arranged

Duration of marriage :

Interpersonal and sexual relations : Satisfactory / unsatisfactory

Extramarital relationship if any specifies:

J. Premorbid Personality

Interpersonal relationship : Extrovert / introvert

Family and social relationships :

Use of leisure time :

Predominant mood : Optimistic / pessimistic; stable / fluctuating; cheerful /

despondent

Usual reaction to stressful reaction :

Attitude to self and others : Self appraisal of abilities, achievements and failures

Attitude to work and responsibility :

Religious beliefs and moral attitudes :

Fantasy life : Daydreams a frequency and content

Habits

Eating pattern : Regular / irregular

Elimination : Regular / irregular

Sleep : Regular / irregular

Use of drugs, tobacco, alcohol