M.Sc (N) Mental health nursing, history collection

1. By- Ms. Snehal Kapadiya
M.Sc (N)
Mental Health Nursing

2. I. Demographic data
 Name
 Age
 Sex
 Marital status
 Religion
 Occupation
 Socio-economic status
 Informant
 Address
 Information (relevant or not), adequate or not

3. II. Presenting chief complaints
(chief complaints/ present complaints)
 In patients own word and in infomant’s own word.
Eg., sleeplessness × 3 weeks
 Loss of appetite and hearing voice × 3
weeks
 talking to self × 3 weeks

4. III. Present psychiatric history
(history of present illness)
 Duration (days, week, months, year)
 Intensity- same/increasing or decreasing
 Mode of onset- acute (within few hours)
 sub acute (within few weeks)
 chronic (within few years)
 Precipitating factors- yes/no, if yes explain
 History of current episode- (explain in detail regarding the
present complaints)
 Associated disturbance- include present medical problems
 Eg., disturbance in sleep, appetite, IPR, social functioning and occupation.

5. IV. Treatment History
 Drugs: (name of the drug, dose, route, side-effect)
 ECT :
 Psychotherapy:
 Pharmacotherapy:
 Rehabilitation:

6. V. Past psychiatric and
medical history
 Number of episode with onset & course
 Complete or incomplete remission
 Duration of each episode
 Treatment details & its side effects if any
 Treatment outcomes
 Detail if any precipitating factors if present
 Substance use detail
 Surgical procedure/ accidents/ head injury/
convulsions/ unconsciousness/ DM/ HTN/ CAD/
Venereal disease/ HIV positivity/ any other

7. VI. Family History
 Family genogram – 3 generations include
onlygrandparents.
 But if there is a family history include the particular
 generation

8. VII. Personal History
a) Perinatal history –
 Antenatal period: maternal infections/
exposure to radiation/ any other
 Intranatal period: type of delivery- normal/
instrumental/ CS
 -Breath & cried at birth
 - Birth defects

9.  Postnatal complications: cyanosis/ convulsion/
jaundice / neonatal infection/ any other
 Mile Stones: - Normal or delayed

10. B) Childhood history
 Primary caregiver
 Feeding: breast feed/ artificial mode of feeding
 Age at weaning
 Developmental milestones

11.  Behaviour during childhood:
- Excessive temper tantrums
- Thumb sucking
- Stuttering OR stammering
- Feeding habit
- Head banging
- Neurotic symptoms
- Pica
- Enuresis
- morbid fears
- Night terrors
- somnambulism
- Habit disorders
- Excretory disorders etc.

12.  Illness during childhood:
-specifically for CNS infections
-epilepsy
- neurotic disorders
- malnutrition

13. C) Educational history
 Age at beginning of formal education:
 Academic performance:
 Extracurricular achievement:
 Relationship with peers and teachers:
 School phobia:
 Look for conduct disorder: eg. Stealing
 Reason for terminating studies

14. D) Play history
 Games played:
 Relationship with playmates:
E) Emotional problems during Adolescence
 Running away from home
 Delinquency
 Smoking
 Drug abuse
 Any other

15. F) Puberty
 Age at appearance of secondary sexual characteristics
 Anxiety related puberty changes
 Age at menarche (in females)
 Reaction to menarche
 Cycle regularities, duration of flow
 Abnormalities if any

16. G) Obstetrical history
 LMP
 Number of children
 Abnormalities associated with pregnancy, delivery,
puerperium:
 Termination of pregnancy if any
 Menopause (including any associated problems)

17.  H) Occupational history
- Age of joining job
- Job hold in chronological order
- Any changes in the job – if any, give
reason
- Current job satisfaction
*(Relationship with superiors,
subordinates & colleagues)
- Reasons for changing jobs
- Whether job is appropriate to
patient’s background

18. I) Sexual and marital history
 Genogram

19. EXAMPLE:

21.  Type of marriage
 Duration of marriage
 Interpersonal and sexual relationship: satisfactory or
unsatisfactory
 Extramarital relation if any

22. VIII. Premorbid Personality
(Personality of a patient consists of those
habitual attitudes & patterns of behaviour
which characterize an individual.
Personality sometimes changes after the
onset of an illness. Get a description of the
personality before the onset of the illness.
Aim to build up a picture of the individual,
not a type. Enquire with respect to the
following areas)

23. 1. Attitude to others in social, family & sexual
relationship:
 Ability to trust other, make & sustain relationship,
anxious or secure, leader or follower, participation,
responsibility, capacity to make decision, dominant or
submissive, friendly or emotionally cold, etc. difficulty
in role taking – gender, sexual, familial.
2. Attitudes to self:
 Egocentric, selfish, indulgent, dramatizing, critical,
depreciatory, over concerned, self conscious,
satisfaction or dissatisfaction with work. Attitudes
towards health & bodily functions. Attitudes to past
achievements & failure, & to the future.

24.  3. Moral & religious attitudes & standards:
 Evidence of rigidity or compliance, permissiveness or over
consciousness, conformity, or rebellion. Enquire
specifically about religious beliefs.
 4. Mood:
 Enquire about stability of mood, mood swing, whether
anxious, irritable; worrying or tense. Whether lively or
gloomy. Ability to express & control feelings or anger,
anxiety, or depression.
 5. Leisure activities & hobbies:
 Interest in reading, play, music, movies etc. enquire about
creative ability. Whether leisure time is spent along or with
friends. Is the circle of friend large or small?

25.  6. Fantasy life:
 Enquire about content of day dreams & dreams.
Amount of time spent in day dreaming.
 7. Reaction pattern to stress:
 Ability to tolerate frustrations, losses,
disappointments, & circumstances arousing anger,
anxiety or depression. Evidence for the excessive use of
particular defense mechanism such as denial,
rationalization, projection, etc.

26.  8. Habits:
 Eating pattern: regular/ irregular
 Elimination: regular/ irregular
 Sleep: regular/ irregular
 Use of drugs, tobacco, alcohol: yes or no, if yes give
details.