Psychiatric Interview:

1.DEMOGRAPHIC DATA OF THE PATIENT.

a. Name:
b. Age:
c. Marital states:
d. Education:
e. Address:
f. Sex:
g. Occupation:
h. Informant:
I.
II.
III.
IV.

Name:
Age:
Relation with the patient:
And acquaintance:

Presenting Complains:

History of Presenting Complains:

Past History:
a) Past Psychiatric History:

b) Past Medical History:

Family History:
Father:
Alive or dead:
Age:
Level of personal health:
Occupation:
Relationship with the patient:
Mother:
Alive or dead:
Age:
Level of personal health:
Occupation:
Relationship with the patient:

Sibs:
Alive or dead:
Age:
Level of personal health:
Occupation:

Relationship with the patient:

Patient:
Hierarchy:
Socio economic condition of the family:
Kind of family ( upper class, middle class, lower class)

Living status of the family. (accommodation,

owner/rented house, financial status of the family:

Any history of physical or mental illness in the

family:

Any History of Drug Dependance in the Family:

Personal History:
a) Gestational period:

b) Birth History:

c) Early development history:

d) Middle Child hood:

e) Adolescence:

f) Early adult hood:

g) Middle and Older adult hood:

h) H/O Drug Dependence or Forensic History:

Premorbid Personality: ( LMCH AR):

General Physical Examination:

anemia,
jaundice,
odema,
synosis,
clubbing,
kolinechia,
paronochia.

Systemic examination:
Detail examination of GIT,
CVS,
CNS,
Respiratory system,
and Genitourinary system.

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Mental State Examination:

General Condition and Behavior:
a) General Appearance.

b) Facial Appearance.

c) Posture and Movements.

d) Social Behavior.

e) Attitude towards examiner and

rapport.

Speech:
Quantity:

Quality:

Flow of speech:

Mood:

Depersonalization and Derealization:

Obsessive Compulsive Phenomenon:

Delusions:

Hallucinations:

Cognitive Processes:
a)

Orientation.
Time:
Place:
Person:

b)

Concentration.

c)

Memory.
Immediate:
Short term:
Long term:

d)

Abstract thinking.
Reasoning:
Judgment:
Proverb:

e)

Insight.

Nominal Dysphasia:

Point to a pencil and a watch. Have

the patient them as you point.

Co-ordination:

Have the patient repeat (no ifs and

buts) and ask him to repeat again
and again.

Comprehension:

Ask the patient to follow a 3 stage

command. Take this paper in your
hand, layer it into 2 and keep it on
the floor.

Reception:

Have the patient read and obey the

following: close both your eyes .
Expression:
Have the patient write a sentence of
his choice which should make sense.
Ignore spelling errors when scoring:
Aslam is going to Burraidh

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Management Plan:

Immediate:
Inpatient / outpatient.

Criteria for admission:

Emergency treatment:

Short term:
Investigations:
Labs:

Psychological:
Interview family to gather information:
Interview Nursing staff to gather information:
Interview friends/relatives/teachers to gather
information:
Self observation:
Psychometry:

Radiological:

Differential Diagnosis:
1.
2.
3.
4.
Tentative diagnosis:

Points in favor of tentative diagnosis:

Points, why you decided not to go for the other

two differentials:
2.

3.

Treatment Plan:

Long term treatment:

Discharge Plan:

Treatment on Discharge:

Follow up:

Prognosis:
Short term Prognosis:

Long term Prognosis:

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