COLLEGE OF NURSING

- : - Psychiatric Nursing History - : Name of the student :

Year
:

I.

IDENTIFYING DATA: Name of the Patient:

Age:
Sex: .
Ward No.: Hospital Regd. No.:
Education: .
Occupation: .
Income: ...
Marital Status: .
Religion: ..
Address: ..
Date of Admission:
Duration of Nursing: ...

Final Diagnosis: ..

II.

a) INFORMATE
b) RELIABILITY OF INFORMANT

III.

PRESENTING COMPLAINTS OR PROBLEMS: According to the patient:

According to the Relative:

IV.

HISTORY OF PRESENTING COMPLAINTS: -

V.

PAST HISTORY OF ILLNESS: -

VI.

Medical Illness

Psychiatric Illness

PERSONAL HISTORY: -

Infancy

Childhood

Adulthood

Late Maturity

VII. FAMILY HISTORY

VIII. PREMORBID PERSONALITY