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History Collection

The document is a comprehensive patient history collection form used for gathering detailed information about a patient's identification, medical history, and psychosocial background. It includes sections on patient demographics, chief complaints, biological functions, psychiatric and medical history, family and socio-economic history, personal history, premorbid personality, and various other factors relevant to mental health assessment. This structured approach aims to facilitate thorough evaluations and treatment planning for patients.

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Raj
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7 views4 pages

History Collection

The document is a comprehensive patient history collection form used for gathering detailed information about a patient's identification, medical history, and psychosocial background. It includes sections on patient demographics, chief complaints, biological functions, psychiatric and medical history, family and socio-economic history, personal history, premorbid personality, and various other factors relevant to mental health assessment. This structured approach aims to facilitate thorough evaluations and treatment planning for patients.

Uploaded by

Raj
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

1

HISTORY COLLECTION

PATIENT IDENTIFICATION DATA


Name :
Age :
Sex :
[Link] :
Date of Admission :
Diagnosis :
Ward :
Educational Status :
Occupational Status :
Income :
Marital Status :
Address :
Religion :
Nationality :
Mother Tongue :
Date of Care Started :
Date of Care Ended :

INFORMANT DETAILS
Name :
Relationship with the patient :
Duration of Stay with the patient :
Reliability :
Adequacy :

CHIEF COMPLAINTS
According To Patients
According To Informant

BIOLOGICAL FUNCTIONS
Sleep : Regular/ Irregular
Appetite : Regular/ Irregular
Bowel : Regular/ Irregular
Bladder : Regular/ Irregular

HISTORY OF PRESENTING ILLNESS


 When the patient was last well or asymptomatic
 Onset
 Duration of symptoms
 Symptoms in chronological order
 Condition of patient at the time of admission
 Use patient’s own words
 Predisposing factors
 Precipitating factor
2

 Perpetuating factor and or relieving factor


 Presence of suicidal ideation
 Ideas of self harm
 Ideas of harm to others
 History of alcohol or drug use

PAST PSYCHIATRIC HISTORY


 Past psychiatric illness
 Psychiatric Hospitalization
 Past Treatment
 Response to the treatment received
 Adverse effect
 Number of Admission
 Treatment for alcoholism or drug abuse

PAST MEDICAL AND SURGICAL HISTORY


Head injury/ convulsions/unconsciousness/ diabetes mellitus/hypertension/coronary
artery disease/syphilis and HIV positive

FAMILY HISTORY
 Genogram /Pedigree chart for 3 generations
 History of Mental Illness
 Ran away
 Suicide
 Mental Retardation
 If there any other psychiatry problem

SOCIO ECONOMIC HISTORY


 Bread winner of the family
 Income of the family

PERSONAL HISTORY
1. Perinatal history:
 Antenatal History
- Illness/ Trauma
- Drugs taken During Pregnancy
- Any psychiatric problem during pregnancy
- Vaccination

 Intranatal
- Full term/ Premature/ Post mature
- Type of Delivery

 Postnatal
- Birth Cry - Immediate / Delayed
- Cyanosis/ Convulsion/ Jaundice/ any other

2. Child hood history:


3

 Brought up by / Maternal Deprivation


 Breast Feeding/ Weaning
 Milestones
 Toilet training
 Neurotic Traits(Stammering, Tics, Enuresis, Encopresis, Night Terrors,
Thumb Sucking, Nail Biting, Head Banging, Body Rocking, Morbid Fears or
Phobias, Somnambulism, Temper Tantrums)

3. Educational history:
 Age at beginning of formal education
 Academic achievements
 Relationship with peers and teachers
 School Phobia/Non-attendance/Truancy/ any learning difficulties/ Reason for
termination of studies (if occurs prematurely)

4. Play history:
 Type of play
 Relationship with peers

5. Puberty:
 Age at menarche
 Reaction to menarche
 Age at appearance of secondary sexual characteristics/Any anxiety related to
changes in puberty

6. Menstrual and Obstetric history:


 Regularity/ Duration of menses/ Length of each Cycle/Any abnormalities
 The last menstrual period
 Number of children born
 Termination of Pregnancy
 Menopause

7. Occupational history:
 Age at starting work
 Jobs held in chronological order/ Reasons for changes/ Job satisfaction/
Ambitions/ whether the job is appropriate to the educational and family
background
 Relationships with authorities, peers and subordinates
 Present income
4

8. Marital and Sexual history:


 Type of Marriage/ Divorce/ Separation
 Sexual activity/ Pre or extra marital relationship/ Contraceptive measures
used/ Any Psychosexual Dysfunction

PREMORBID PERSONALITY
1. Interpersonal relationship
 With family members, friends and colleagues
 Introverted/Extroverted
 Ease of making and maintain social relationship

2. Use of leisure time


 Hobbies/ Interests
 Energetic/Sedentary

3. Predominant Mood
 Optimistic/ Pessimistic
 Stable/ Prone to Anxiety
 Cheerful
 Reaction to stressful life events

4. Attitude to self and others


 Self Confidence / Self Criticism
 Self Centered/ Thoughtful of others/ Self appraisal of abilities, achievements
and failures

5. Attitude to work and responsibility


 Decision making/ Acceptance of responsibility/ Flexibility/perseverance/
foresight

6. Religious beliefs and moral attitudes


 Religious beliefs/ Tolerance of others/ Standard and Beliefs/ Conscience/
Altruism

7. Fantasy life
 Sexual and nonsexual fantasies
 Daydreaming- frequency and content
 Favorite daydreams
8. Habits
 Food fads, alcohol, tobacco, drugs and sleep

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