Psychiatric History | PE and MSE Date of Interview: / / Time: Start End

Identifying Data History of Present Illness

Full Name □ Problems
Address (e.g., worries;
preoccupations;
Sex/Age (B-day) M. Status changes in mood;
suspicions; delusions or
Occupation Religion hallucinatory
experiences; recent
Citizenship/Ethnicity Handedness:… Rt … Lt … Ambi changes in sleep,
appetite, libido,
Referral concentration, memory,
Informant Sex/Age or behavior, including
suicidal or aggressive
Relation to Pt. Reliability behaviors)
□ Severity
Chief Complaint □ Time Course
o Onset
Pt’s o Duration
Informant’s □ Stressors/
[Notes] Conflicts
(i.e., home, work,
school, legal, medical
comorbidities,
interpersonal difficulties)
□ Key Factors/
Events
Past Psychiatric and Medical History (e.g., medications,
□ Psychiatric Illness coping skills, time of
day)
(e.g., Emotional or mental
disturbances – age of oPrecipitating
onset, course of illness, oExacerbating
specific symptoms,
hospitalizations, treatment oAlleviating
and effect of treatment)
□ Associated S/Sx
□ Psychosomatic (i.e., Pertinent Positives
disorders and Negatives)
(e.g., colitis, skin conditions, o Dysfunction
etc.)
o Psychophy-
□ Medical Conditions/ siological Sx
Comorbidities o Pertinent
(e.g.,including pertinent
childhood illnesses, injuries, positives
hospitalizations, surgeries,
etc.)
□ Alcohol and Other
□ Reason for
present consult
Substance History
( Amount and Duration of □ Premorbid
use; Precipitants, Attitude Consultations
toward use; History of
withdrawal; Longest time
sober; Past treatment)
Suicide
□ Medication History
□ Lethality
□ Allergies
□ Intent
□ Attitude
□ Family Support

Family Medical History

□ Psychiatric or
Neurological Illness
(e.g., "nervous
breakdown", depression,
schizophrenia,
alcoholism, substance
abuse, mental deficiency,
delinquency, legal
difficulties, suicide, Review of Systems
suicide attempts,
"neuroses", epilepsy,
… Unremarkable/Essentially Normal
syphilis, hospital care, and … Weight Change _______________ … Headache … Dizziness
psychotherapy.)
… Fever/Chills … Night sweats … Head Injury … Jaundice
□ Medical Conditions
System Details (Significant Findings)
o HPN … EENT … Eye: blindness | blurring of vision | diplopia | FB sensation
o MI discharge | redness | tearing
o CVA/TIA … Ear : discharge | pain | tinnitus
o CA … Nose: sneezing | congested | runny | discharge | epistaxis
o DM … Oral cavity and throat: toothaches| bleeding gums
o PTB hoarseness | dysphagia | oral ulcers
o BA/Allergy … Others:
o Liver D/O … Pulmonary … Cough _________ … Chest pain … Dyspnea … Hemoptysis
o Thyroid D/O … Cardiovascular … Palpitations … Orthopnea (no. of pillows:_____) … PND
o Kideney D/O … Edema … Claudication
o Others … Gastrointestinal … Nausea | vomiting … Abdominal pain
… Heartburn … Dyspepsia: indigestion | belching | flatulence
[Genogram] … Diarrhea … Constipation … Changes in stool
… Genitourinary … Dysuria … Hematuria … Lithuria … Incontinence
… Hesitancy … Intermittency … Nocturia (____ x/night)
… Weak stream … Urgency … Retention … Frequency
… Hematologic … Easy bruisability … Impaired clotting … Pallor
… Endocrine … Polyuria … Polyphagia … Polydipsia … Alopecia
… Heat | Cold intolerance … Easy fatigability … Hirsutism
… Neurologic … Numbness/paresthesias … Incoordination
… Musculoskeletal … Limitation of movement
… Joint: pain | swelling | redness
… Stiffness
… Muscle spasm | weakness
… Ob-Gyne … Quickening … Morning sickness … Vaginal Discharge
… Dermatologic … Rashes … Pruritus … Other skin lesions
[Notes]

Alphius’ Psychiatric Hx, PE and MSE Form (2012)

Psychiatric Review of Symptoms (PROS) Personal and Social History (Anamnesis)
Major Depression/Dysthymia Period Key Events/Developmental Milestones
[Depressed Mood] Have you had periods of feeling sad, miserable or hopeless? Prenatal … Full-term … Premature … NSVD … CS
… Planned … Unplanned … Wanted … Unwanted
S Have you had trouble sleeping? (initial, middle, terminal)
Age of: mother ______ (G__P__[ ]) & father ______ at birth
I Have you noticed a change in your interest in things you normally enjoy? … Complications/problems:
G Have you been feeling down on yourself? Guilty about anything?
E Have you tended to feel more tired than usual? As if all your energy is drained? Infancy [ Dev’l Milestones; Warning signs present]
(Birth-15 mos old)
C Have you had trouble concentrating? Making decisions?
A Have you had any changes in your appetite? Lost or gained weight?
Toddler period [ Feeding habits, general conduct and behavior, temperament/personality as a child,
P Have you felt restless or agitated? Have you been feeling slowed down? relationship with parents or caregivers and peers, separation anxiety, etc.]
S Have you ever felt that life isn’t worth living? Thought about taking your own life?
(15 mos-2½ y/o) • Feeding habits: … Breast-fed … bottle-fed
… eating problems
SIGECAPS = SIG + Energy + CAPSules
Pre-school • Early development: Maternal deprivation, language development, motor
Sleep (hypersomnia or insomnia)*, Interest (anhedonia), Guilt (inappropriate guilt, feelings of
development, signs of unmet needs, sleep pattern, object constancy,
worthlessness*, hopelessness*, regret), Energy (decreased)*, Concentration (decreased)* (2½ y/o-6 y/o) stranger anxiety, separation anxiety
Appetite (increased or decreased)*, Psychomotor agitation/retardation, Suicidal ideation
MAJOR DEPRESSION: > 4 symptoms + depressed mood + anhedonia for > 2 weeks
DYSTHYMIA: > 2 of the 6 symptoms with * + depression for > 2 years (adult) or > 1 year • Toilet training: … Age ____; attitude of parents, feelings about it
(children)
Manic Episode • Symptoms of behavior problems: … thumb sucking,
Have you had periods of feeling so happy or energetic that your friends told you were … temper tantrums … tics … head bumping … rocking
talking too fast or that you were too ‘hyper’?” … night terrors … fears … bed-wetting or bed soiling
D Have you been easily distracted by external stimuli even if they are unimportant or … nail biting … masturbation
seems irrelevant? • Personality and temperament as a child: … shy … restless
I Have you done anything that caused trouble for you or your family/friends? … overactive … withdrawn … timid … friendly
… studious … outgoing … athletic
G Have you ever felt extremely good or high, clearly different from your normal self?
… patterns of play
F Have you felt your thoughts are racing through your mind? …pressured speech? … reactions to siblings
A Have you been more active than usual in goal-directed activity at work, at school,
or sexually? Middle Years [ Early school history feelings about going to school, early adjustment, gender
identification, conscience development, punishment; social relationships, attitudes
S Did you need less sleep than usual to feel rested? (6 y/o-12 y/o) toward siblings and playmates]
T Have you been more talkative than usual?
DIGFAST = Distractibility ((i.e., attention too easily drawn to unimportant or irrelevant external
stimuli)), Indiscretion (excessive involvement in pleasurable activities that have a high potential
for painful consequence), Grandiosity (inflated self-esteem), Flight of ideas (subjective
experience that thoughts are racing), Activity increase or psychomotor agitation), Sleep deficit
(e.g., feels rested after only 3 hours of sleep), Talkativeness (pressured speech) Adolescence [ Peer relationships, school history, special interests, psychosexual history,
drug/alcohol use, work experience, etc.]
MANIC EPISODE: > 1 week of elevated or irritable mood + 3 of 7 symptoms above (12 y/o-20 y/o)
Borderline Personality Disorder
Have you had periods of feeling so happy or energetic that your friends told you were
talking too fast or that you were too ‘hyper’?”
I Do you have trouble knowing who (say patient's name) is?
Occupational
D Are you a moody person? History
E Do you often feel empty inside?
S When something goes really wrong in your life, like getting rejected, do you ever
do something to hurt yourself, like cutting yourself or overdosing? Marital &
P When you're under stress, do you feel like you lose touch with your environment Relationship
or with yourself? During those times, do you feel like people are ganging up History
against you?
A When someone abandons you or rejects you, how do you react?
I Do you ever get really impulsive and do crazy things, like going on spending
sprees, having a lot of sex, driving like a maniac and so forth?
R What do you do when you get angry—do you hold it inside or let loose with it so
everybody knows how you're feeling?
R Do your relationships tend to be calm and stable or stormy and with lots of ups Military History
and downs?
I DESPAIRR = Identity problem, Disordered affect, Empty feeling, Suicidal behavior, Paranoia
or dissociative symptoms, Abandonment terror, Impulsivity, Rage, Relationship instability
BORDERLINE PERSONALITY DISORDER: Pt must have an enduring pattern of > 5 of 9 traits
Adulthood/Present Life

above Educational
Substance Abuse Disorder (Screen for Alcoholism) History
C Have you ever felt you needed to Cut down on your drinking?
A Have people Annoyed you by criticizing your drinking?
Religion
G Have you ever felt Guilty about drinking?
E Have you ever felt you needed a drink first thing in the morning (Eye-opener) to
steady your nerves or to get rid of a hangover?
Two "yes" responses indicate that the possibility of alcoholism should be investigated Social Activity
Anxiety Disorder: Panic Disorder with Agoraphobia
1. Have you ever experienced a sudden attack of panic or fear in which you felt extremely
uncomfortable? Did you feel as if you were going to die or go crazy?
2. Ever been afraid of going outside, so that you tended to stay home all the time? Current Living
Situation
Anxiety Disorder: Obsessive-Compulsive Disorder
1. Are you ever bothered by persistent ideas that you can’t get out of your head, such as
being dirty or contaminated?
2. Is there anything you have to do over and over, such as washing your hands or
checking things?
Psychosis
1. Persecutory: Have you felt that people are against you? Trying to harm you in
any way
Delusions

2. Grandiose: Do you have any special powers, talents or abilities?

3. Thought broadcasting: Have you heard your own thoughts out loud, as if they
were a voice outside your head? Have you felt that your thoughts were Legal History
broadcast so that other people could hear them?
Hallucinations Have you heard voices no one else could hear? When no one was
around and you couldn’t account for them? Seen things?
Sexual History Age at Coitarche: _____ Menarche: _____ Andro/Menopause:
Also screen for Somatization disorder (Recipe 4 Pain: Convert 2 Stomachs to Menstrual flow: ____ ppd Duration: _____ Interval: _____
• Sexually-active:
1 Sex: The presence of four pain symptoms, one conversion symptom, two gastrointestinal
…Y…N … Dysmenorrhea … OCP | IUD use LNMP: IPMP:
symptom and one sexual symptom.), Eating Disorders (“Have you ever felt like you are Masturbating: … Y … N Age started: ________
overweight?”) and Cognitive disorders (dementia [Check orientation, memory Number of sexual partners: ____________ Orientation:
and fund of knowledge], delirium). Practices unprotected sex : … Y … N
… Sexual Concern(s)

Fantasies and [Fantasies about the future, daydreams, nightmares., etc. esp prominent/recurrent ones]
Dreams

Values [Concept of right and wrong, values for money, studies, work, children, parents, sex,
community concerns and cultural issues

Alphius’ Psychiatric Hx, PE and MSE Form (2012)

Physical Examination Mental Status Examination
General: … Seated … Lying on bed … Standing … Walking around
FACIAL … Calm … Sad … Worried … Hostile
BP: EXPRESSION … Avoiding gaze … Others
Vital Signs: HR: PR: Temp:
GROOMING … Kempt … Unkempt … Disheveled

General Appearance
Anthropometrics Ht: Wt: BMI: … Others
System Significant Finding
CLOTHING … Appropriate* … Inappropriate … Seductive
Skin … With layers of clothing … Others
HEENT … AS … PPC … EBRTL Pupils: ______ mm … Full EOMs *according to age, sex, occasion or weather
… TNM … ANM … CLAD MOTOR
… Rigidity … Hypoactivity … Tremors
ACTIVITY
… Echopraxia … Waxy flexibility … Impulsive
… Peculiar Posturing … Others
INTERVIEW … Cooperative … Uncooperative … Irritable
Chest/Lungs … ECE … CBS … Rales/Wheezes … Retractions BEHAVIOR … Evasive … Aggressive
… Passive … Manipulative … Demanding
… Frank … Defensive
VOLUME … Normal … Soft … Loud … Mumbled

Speech
… AP … DHS … NRRR … Murmur … Heaves/Thrills QUALITY … Normal … Incomprehensible … Overly dramatic
Heart
RATE … Normal … Slow … Pressured
… Prodded to respond … Others
Others: … Spontaneous … Able to reach a conversation goal
Mood … Calm … Depressed … Euphoric … Anxious
Abdomen … NABS _____/min … Soft | Globular | Flat | Non-distended … Euthymic … Giggling … Angry …
… Tenderness: Affect … Appropriate … Inappropriate … Flat … Blunted
… IntactTraube’s Space … Span of Liver Dullness … Constricted … Expansive … Others
… Visual, Pt sees
… Auditory, Pt hears

HALLUCINATIONS
… Command
Genitalia/ It is of the … Commentary type

Perception
Rectal … Tactile, Pt feels
Extremities … PNB … Cyanosis … Clubbing … FEP … Olfactory, Pt smells
… Gustatory
*Circumstance of occurrence:
Patient is …responding … not responding to the non-existent stimuli
Neurological Examination … Illusion … Derealization …Depersonalization … Déjà Vu
Cranial Nerves … Logical … Relevant … Organized … Good flow
I … Able to identify odors correctly … Thought process disorders (Specify)
II … Vision Intact | VA:: OD: ____________ OS: ____________ … Thought blocking … Perseveration
THOUGHT
PROCESS

III, IV, VI … Full EOMs … Circumstantiality … Clanging

… Able to clench jaw … Intact corneal reflex … Tangentiality … Echolalia
V
… Flight of Ideas … Poverty of speech
VII … No facial asymmetry … Looseness of association … Pressured speech
VIII … Intact hearing and balance … Ideas of reference … Thought insertion
Thiiking

IX, X … Intact gag reflex … Neologism … Thought withdrawal

XI … Good, symmetrical shrug … Preoccupations:
… Able to head turn against resistance … Sexual … Religious … Phobia/Fear
XII … Tongue Midline … Death … Suicide … Homicide
THOUGHT
CONTENT

Sensory Function Motor Function … Obsession … Compulsion

… Delusion
… Persecutory … Grandiose … Bizarre … Somatic
… Jealous … Guilty … Erotic … Nihilistic
… Others
… Ideas of reference … Ideas of influence
ALERTNESS: … awake … drowsy … stuporous … coma
ORIENTATION OF TIME, PLACE & PERSON:
Person: … knows self … knows the bantay
Time: … time of day … day … month … year
… date … weather/season
Cerebellar Examination, etc.. Deep Tendon Reflexes
Place: … Floor … Hospital … Street
… Nystagmus
… City … Country
… Dysarthria
CONCENTRATION:
… Arm Dysmetria
Pt. can spell: … M-U-N-D-O … O-D-N-U-M
{ Postural Tremor
… <name> … <name, backwards>
{ Positional Tremor
… random no. sequence: 6-2-7-8-7
… Dysdiadochokinesia
CALCULATION: … [ 100 – 7 – 7… ] … [ 17 + 5 + 5…]
… Leg Dystaxia
Sensorium

… Multiply these numbers: (25 x 6)

… Hypotonia
MEMORY, RECENT AND REMOTE:
… Romberg Test
Immediate: … repeat “kamay-puti-Antipolo City”
… Normal stance | gait
Remote: … no. of children/siblings … name of mother/father
… Nuchal rigidity
… Able to recall past news/event
… “What do you had for breakfast/last supper?
The Mini-Mental State Exam Recent: … recall after 5 minutes: “kamay-puti-Antipolo City”
FUND OF INFO: … Past 5 Philippine Presidents
… Election month?
… Letters in the alphabet?
ABSTRACT THINKING:
Similarities: … “Chair” and “desk” … “Watch” and “Ruler”
Proverbs: … “Kapag maiksi ang kumot, matutong mamaluktot.”
… “Ang hindi lumingon sa pinanggalingan ay hindi
makakarating sa paroroon.”
… “Two heads are better than one.”
… Complete denial of illness
… Slight awareness of being sick and needing help, but denying it at the
same time
… Awareness of being sick but blaming it on others, on external
factors, or on organic factors
Insight

… Awareness that illness is caused by something unknown in the

patient
… Intellectual insight: admission that the patient is ill and that symptoms or
failures in social adjustment are caused by the patient's own particular irrational
feelings or disturbances without applying this knowledge to future experiences
… True emotional insight: emotional awareness of the motives and feelings
within the patient and the important persons in his or her life, which can lead to
basic changes in behavior.
Intellectual Educational attainment:
Capacity … Bright … Average … Dull … Mentally Retarded … Demented
Judgment “Nasa loob ka ng sinehan nang may naamoy kang usok, ano ang iyong unang gagawin?”
… Good … Fair conf… Poor
Other observations:

Alphius’ Psychiatric Hx, PE and MSE Form (2012)