Here is the format for taking detailed history of patients with mental illness.This content included the meanings of terms also.So that it will be easy to understand for everyone including psychiatrists,nurses & student nurses.It gives a good understanding of a patient & helpto identify the patients diagnosis.It is also very useful for planning the appropriate treatment of a patient & identifying & fulfilling the needs of the patient as well. #mentalhealth#psychiatrichistory#education#mentalhealthnurse#psychiatrist#mentalhealthexist#datacollection#nursingstudents#nursestudymaterials

1. PSYCHIATRIC HISTORY
TAKING FORMAT
BY:
Akanxa Rao
Assistant professor
GUNI-KBION

2. IDENTIFICATION DATA
• NAME:
• AGE:
• SEX:
• FATHER/SPOUSE:
• ADDRESS:
• EDUCATION:
• OCCUPATION:
• INCOME:
• MARITAL STATUS:
• RELIGION:
• INFORMANT:
• INFORMATION:RELEVANT/NOT
RELEVANT,ADEQUATE/NOT ADEQUATE

3. PRESENTING CHIEF COMPLAINT
• (WITH DURATION IN CHRONOLOGICAL
ORDER,IN PATIENT’S OWN WORDS &
INFORMANT’S OWN WORDS)

4. HISTORY OF PRESENT ILLNESS
• DURATION(DAYS/WEEKS/MONTHS/YEARS):
• MODE OF ONSET(The length of time it takes for a
symptoms to start to
completely):ABRUPT(SUDDEN)(<48
HOURS)/ACUTE(<1 WEEK)/SUBACUTE(1-
2WEEKS)/INSIDIOUS(SLOWLY)(WITHIN A FEW
WEEKS)

5. • COURSE(the development of symptoms including the
sequence & the speed it
takes):CONTINUOUS/EPISODIC/FLUCTUATING/DETER
IOTING(GETTING WORSE)/IMPROVING/UNCLEAR
• INTENSITY(તીવ્રતા):SAME/INCREASING/DECREASING
• PRECIPITATING FACTORS(triggering factors-ઉત્તેજક
પરિબળો):YES/NO,IF YES EXPLAIN
• DESCRIPTION OF PRESENT ILLNESS:

6. TREATMENT HISTORY
• DRUGS(NAME OF THE
DRUG,DOSE,ROUTE,SIDE-EFFECTS,IF
ANY):
• ECT:
• PSYCHOTHERAPY:
• FAMILY THERAPY:
• REHABILITATION:

7. PAST PSYCHIATRIC & MEDICAL
HISTORY
• NUMBER OF PREVIOUS
EPISODES/HOSPITALIZATION(PSYCHIATRIC)WIT
H ONSET & COURSE:
• COMPLETE OR INCOMPLETE
REMISSION(RECOVERY):
• DURATION OF EACH EPISODE:
• TREATMENT DETAILS & IT’S SIDE EFFECTS IF
ANY:
• TREATMENT OUTCOME:

8. • DETAILS OF ANY PRECIPITATING
FACTORS IF PRESENT:
• SUBSTANCE USE DETAILS:
• SURGICAL
PROCEDURES/ACCIDENTS/HEAD
INJURY/CONVULSIONS/UNCONSCIOUSNE
SS/DM/HTN/CAD/VENEREAL
DISEASES(SEXUAL DISEASES)/HIV
POSITIVITY//ANY OTHER

9. FAMILY HISTORY
• DESCRIPTION(TABLE)
• GENOGRAM

10. PERSONAL HISTORY
• PERINATAL HISTORY
ANTENATAL PERIOD:MATERNAL
INFECTIONS/EXPOSURE TO RADIATION/ANY OTHER
CHECK UPS
ANY COMPLICATIONS
INTRANATAL PERIOD:TYPE OF DELIVERY-
NORMAL/INSTRUMENTAL/CESEARIAN
ANY COMPLICATIONS
BIRTH:FULL-TERM/PREMATURE/POSTMATURE
BIRTH CRY:IMMEDIATE/DELAYED
BIRTH DEFECTS:YES OR NO,IF YES,SPECIFY
POSTNATAL
COMPLICATIONS:CYANOSIS/CONVULSIONS/JAUNDIE
NE/NEONATAL INFECTIONS/ANY OTHER

11. • CHILDHOOD HISTORY
PRIMARY CAREGIVER:
FEEDING:BREASTFED/ARTIFICIAL MODE OF
FEEDING
AGE AT WEANING:
DEVELOPMENTAL
MILESTONES:NORMAL/DELAYED
BEHAVIORAL & EMOTIONAL PROBLEM:THUMB
SUCKING/EXCESSIVE TEMPER
TANTRUMS/STUTTERING/HEAD-BANGING/BODY
ROCKING(REPEATATING MOVEMENT OF
BODY)/NAIL BITING/PICA/ENURESIS(NIGHT
TIME BED WETTING)/MORBID FEARS(ABNORMAL
FEAR)/NIGHT TERRORS/SOMNABULISM(SLEEO
WALKING)
ILLNESS DURING CHILDHOOD:SPECIFICALLY
FOR CNS INFECTIONS/EPILEPSY/NEUROTIC
DISORDERS/MALNUTRITION

12. • EDUCATIONAL HISTORY:
AGE AT BEGINNING OF FORMAL EDUCATION:
ACADEMIC PERFORMANCE(SPECIFICALLY
LEARNING DISABILITY & ATTENTION DEFICIT
DISORDERS):
EXTRACURRICULAR ACHIEVEMENTS,IF ANY:
RELATIONSHIPS WITH PEER & TEACHERS:
SCHOOL PHOBIA:YES/NO
LOOK FOR CONDUCT DISORDERS,FOR
EXAMPLE TRUANCY(STAYING AWAY FROM
SCHOOL)/STEALING:YES/NO
REASON FOR TERMINATION OF STUDIES:

13. • PLAY HISTORY
GAMES PLAYED(AT WHAT STAGE & WITH
WHOM):
RELATIONSHIP WITH PLAYMATES:

14. • EMOTIONAL PROBLEMS DURING
ADOLESCENCE:
RUNNING AWAY FROM
HOME/DELIQUENCY(minor crime,
especially that committed by young
people)/SMOKING/DRUG TAKING/ANY
OTHER

15. • PUBERTY:
AGE AT APPEARANCE OF SECONDARY
SEXUAL CHARACTERISTICS:
ANXIETY RELATED TO PUBERTY CHANGES:
AGE AT MENARCHE(STARTING OF
MENSTRUAL CYCLE):
REACTION TO MENARCHE:
REGULARITY OF CYCLES,DURATION OF
FLOW:
ABNORMALITIES, IF
ANY(MENORRHAGIA(menstrual periods with
abnormally heavy or prolonged
bleeding),DYSMENORRHEA(painful menstruati
on),ETC.)

16. • OBSTETRICAL HISTORY
LMP(LAST MENSTRUAL PERIOD):
NUMBER OF CHILDREN:
ANY ABNORMALITIES ASSOCIATED WITH
PREGNANCY,DELIVERY,PUEPERIUM(the
period of about six weeks
after childbirth during which the mother's
reproductive organs return to their
original non-pregnant condition):
TERMINATION OF PREGNANCY,IF ANY:
MENOPAUSE(the time that marks the end
of menstrual cycles),IF ANY(INCLUDING
ANY ASSOCIATED PROBLEMS):

17. • OCCUPATIONAL HISTORY
AGE AT STARTING WORK:
JOBS HELD IN CHRONOLOGICAL ORDER:
REASONS FOR CHANGES:
CURRENT JOB SATISFACTION:
(INCLUDING RELATIONSHIPS WITH
AUTHORITIES,COLLEAGUES,SUBORDINAT
ES)
WHETHER JOB IS APPROPRIATE TO
PATIENT’S BACKGROUND:

18. • SEXUAL & MARITAL HISTORY
GENOGRAM(FAMILY OF PROCREATION-
DETAILS OF SPOUSE & CHILDREN):
TYPE OF MARRIAGE:SELF-
CHOICE/ARRANGED
DURATION OF
MARRIAGE:INTERPERSONAL & SEXUAL
RELATIONS:SATISFACTORY/UNSATISFACT
ORY
EXTRAMARITAL RELATIONSHIP IF ANY
SPECIFY:

19. • PREMORBID PERSONALITY
INTERPERSONAL
RELATIONSHIPS:EXTROVERT/INTROVERT
FAMILY & SOCIAL RELATIONSHIPS:
USE OF LEISURE TIME:
PREDOMINANT
MOOD:OPTIMISTIC(POSITIVE)/PESSIMIST
IC(NEGATIVE),STABLE/FLUCTUATING,CHE
ERFUL(HAPPY)/DESPONDENT(SAD)
USUAL REACTION TO STRESSFUL
EVENTS:
ATTITUDE TO SELF & OTHERS:SELF-
APPRAISAL OF ABILITIES,ACHIEVEMENTS
& FAILURES

20. • ATTITUDE TO WORK & RESPONSIBILITY:
• RELIGIOUS BELIEFS & MORAL
ATTITUDES:
• FANTASY LIFE:DAYDREAMS A FREQUENCY
& CONTENT
• HABITS
EATING PATTERN:REGULAR/IRREGULAR
ELIMINATION:REGULAR/IRREGULAR
SLEEP:REGULAR/IRREGULAR
USE OF DRUGS,TOBACCO,ALCOHOL: