CLINICAL INTAKE AND HISTORY

NAME:

AGE: GENDER: EDUCATION:

OCCUPATION:

INFORMANT :
Who is the informant ? Relationship to client .Note down details from informant separately

PRESENTING COMPLAINTS AND THEIR DURATION :

Chronological order , main disturbances in different areas of functioning.

HISTORY OF PRESENT ILLNESS:

1. Onset : Acute vs sub acute vs gradual
2. Precipitating factors : Physical or Psychological and if they preceded the illness
3. Course of the illness : episodic ,continuous or fluctuating
Demonstrate it graphically if possible
4. Associated disturbances :Sleep, appetite ,weight gain ,sexual life ,social and occupational
life.
Rule out organic etiology like fever ,vomiting ,confusion ,substance abuse ,memory issues or
neurological signs and symptoms esp in the elderly .

PAST HISTORY :
Past physical and Past psychiatric history. Nature and duration of symptoms.
How it was managed and response to treatment .
May overlap with history of present illness.

FAMILY HISTORY :
1. Describe family members. age ,living or dead, education ,occupation ,marital status,
personality and relationship with the patient .
2. Illnesses in the family :physical or psychiatric
3. Socioeconomic status , dynamics within the family ,roles and leadership, communication
patterns

PERSONAL HISTORY :

Early Middle and late childhood :

1. Birth and early development : Pre natal ,natal and post natal.FTND,at home ?
Complications, physical illness at birth , cried normally, Milestones
2. Behaviour during childhood::Sleep disturbances ,nail biting ,thumbsucking, temper
tantrums, bedwetting. Conduct issues ,lying stealing ,Relationship with siblings and parents
.Rivalry
3. Physical illness during childhood: Epilepsy ,febrile convulsions ,meningitis, encephalitis

4. School: Age of starting and ending ,performance ,attitude towards authority figures and
peers ,type of school
5. Occupation :Age of starting work, jobs held ,satisfaction ,competence and ambitions

MENSTRUAL HISTORY:
Age at menarche, attitudes towards menstruation , PMS, dysmennorhea
SEXUAL HISTORY:
Age of onset of puberty , sources of info about sex and attitude, Risk taking behavior
,fantasies ,practices ,Homosexual and heterosexual interactions ,
Contraception, Anxiety related to sex.

MARITAL HISTORY :
Age of marriage , how , quality of marital relationship ,abuse ,extra marital relations,
personality of partner, separation ,children and ages and health

OCCUPATIONAL HISTORY:
Age of starting work ,type of work and hours , works satisfaction , ambition , military work
,changes in job and reasons for that ,issues at work, colleagues

SUBSTANCE USE:
Smoking and drinking pattern ,drug use and abuse

PREMORBID PERSONALITY :

Habitual patterns of behavior before the illness in terms of :

1. Attiudes to others in social ,family and sexual relationships

Ability to trust others, make and sustain relationships,, decision making
,leadership,dominance ,jealousy ,.Role taking in different areas
2. Attitudes to self: Egocentric ,selfish ,critical ,dependent ,satisfaction .Health and
bodily functions .Past achievements and failure.
3. Moral and religious attitudes: Rigid standards, permissiveness, rebellion , religious
beliefs and stringent standards
4. Mood: Mood swings ,irritable ,tense, lively ,anger ,anxiety
5. Lesiure activities and interests: Hobbies and creativity . Spend time with friends
6. Fantasy life: Dreams and day dreams
7. Reaction patterns to stress: Ability to tolerate disappointments , anger arousing
issues, Excessive use of defense mechanisms
8. Habits : Sleeping and excretory functions

MENTAL STATUS EXAMINATION

GENERAL BEHAVIOUR
1. Appearance : Overall impression and posture , body type ,healthy , childlike ,disheveled or
bizarre .Relaxed or tense ,sweating
2. Psychomotor activity :Qualitiative and quantitative aspects . Mannerisms and tics or
gestures,slowing or psychomotor retardation
3. Attitude towards examiner: cooperative ,friendly ,attentive ,seductive ,hostile or guarded.

MOOD and AFFECT : Mood is the pervasive feeling of emotion felt by the patient .Subjective and
objective reports need to be included. Depressed,anxious, irritable ,angry ,euphoric .
Check about depth ,intensity and duration and Labile or rapidly shifting moods.
Affect is the present emotional response observed by clinician. Congruent or non congruent.
Constricted ,blunted or flat. Face immobile .Variation in facial tone and expression
Appropriateness of emotion and affect . Delusions then show anger or fear of persecution .

PERCEPTION : Hallucinations and Illusions

Visual ,olfactory ,auditory or tactile .Hypnagogic and hypnapompic.
Depersonalizations and derealisations . Details of auditory hallucinations
Verbal or non verbal,single or multiple voices, male /female,first person ,second person or third
person ,abusive or threatening .Reaction to hallucinations .

SPEECH : Rate and rhythm of speech

Spontaneous or slow to respond ? Quantity ,rate of production and quality .
Slurred ,monotonous ,excessive speech or poverty of speech. Prosody of speech ,relevant and
coherent
Pressured ,dramatic

THOUGHT: measured through speech output and writing by patient

1. Stream or process : flight of ideas ,retardation of thinking ,circumstantiality ,perseveration
and thought blocking ,Logical ,relevant ,loose associations,
2. Content : Delusions ,obsessions ,phobias ,ideas of reference, Depressive ideas
,worthlessness
3. Formal thought disorder
4. Possession : Obsessions and compulsions , phobias . nature of obsessions and
compulsions , washing ,counting or checking .Are they controlling or yielding ?

COGNITIVE FUNCTIONS:

ATTENTION AND CONCENTRATION :

Consciousness :clouding ,somnolence ,stupor ,lethargy ,alertness or fatigue

Distractibility: ,difficult to arouse attention ?
Concentration :Days of week in reverse order ,serial 7 subtractions or 3 if couldn’t do it .
ORIENTATION : time , place and person . Date . Confabulation

MEMORY :

IMMEDIATE : Repetition of digits , 6digits ,forward and backward

RECENT : what you ate for breakfast or lunch , events of the day .Give an address and recall after
half hour
REMOTE : Personal and impersonal events

GENERAL INFORMATION :
Varied according to background
Name of Prime Minister,Major cities in India .State capital
Chief minister
Name of a few countries etc

INTELLIGENCE :
gauged from educational background and occupation if needed testing may be planned .
Reading and writing

ABSTRACTABILITY ;
Similarities between a table and chair and common differences
.Proverbs: A stitch in time saves nine , Truth and Beauty
The apple does not fall far from the tree

JUDGEMENT :
 1. Personal judgment : attitude to illness .is treatment necessary ?
2. Social Judgement : show any disinhibition , behavior in social situations
3. Test judgment : Envelope in street ,fire in movie theatre

INSIGHT :
No insight ,
intellectual or emotional insight
Intellectual when admits he is ill and due to patients own irrational feelings or disturbances but no
application to his condition
Emotional : emotional awareness of motives and feelings within patient and important people in
life which can lead to changes in behavior

SUMMARY :
Complete description of all aspects in a similar format and chronology .

INITIAL FORMULATION :
Your own assessment of the case . Includes , Diagnosis, Etiological factors , Plan for
management and Estimate of Prognosis.
Every report will have a different length and emphasis .
Provisional diagnosis at least regardless of complexity of case.

INVESTIGATIONS, TREATMENT AND FOLLOW UP :

Biochemical , radiological , psychometric investigations be planned and carried out.
Physical ,psychological and social interventions planned .
Progress notes recorded .

FINAL FORMUALTION :
Revision of initial formulation . Treatments started and revision of diagnosis. Patients response so
far .
Final diagnosis , comments and estimate of prognosis.
Age
Motor skills
Language
3 months Holds head steady Imitates sounds
6 months Can roll over
9 months Sits without support Combines syllables into word-like sounds
12 months Stands alone Uses 20 single words
15 months Walks alone Plays with ball
18 months Carries items while walking Can make two-word sentences
2 years : Can run Can kick a ball forward Child uses own name Asks “Why?” Can name at least six body parts
3 years: Jumps, balances on one foot Uses four to five words in a sentence Use singular and plural
4 years: Bounces Uses past tense, recounts experiences
5 years to 6 years Bounces cross-step Language development completed