Professional Documents
Culture Documents
Name
Ward No.
Age
Unit No.
Sex
Hospital ID :
Address
DOA
Education
Occupation
Income
Marital Status :
Religion
Nationality
Language Spoken :
II. INFORMANTS
Name & age of informant
:
1
Informants version
(Write in a chronological order with duration)
Effects of symptoms on
Self
Other mental functions
Biological functions
Social functions
Interpersonal relations
Law
Suicidal ideations present/ absent
Negative History
Treatment History
Informants Version
Response to Treatment
Legal problems
Attainment of milestone
Age and ease of toilet training
H/o maternal deprivation
Neurotic traits
2. Educational history
3. Play history
6. Occupational history
Hobbies/interests/intellectual activities
Energetic/sedentary
4
background
3. Predominant mood
optimistic/pessimistic
stable/prone to anxiety
cheerful/sad
reaction to successful events
Self-confidence level
Self-criticism
Selfish/thoughtful of others
Self appraisal of abilities
Achievements & failures
Decision making
Acceptance of responsibility
Religious beliefs
Toleration of others standards and beliefs
Conscience
Altruism
7. Habits
Food fads
Alcohol
Tobacco
Drugs
Sleep
8. Fantasy life
Sexual/nonsexual fantasies
Day dreaming-frequency and content
Physique/body built
5
Looks comfortable/uncomfortable
Physical health
Grooming & dressing
Hygiene & self care
Facial expression
Eye to eye contact
2. Attitude towards the examiner
Co-operative / attentive / interested / guarded / defensive / hostile / irritable / aggressive / friendly /
playful / seductive / evasive.
3. Gait & Posture
4. Rapport
5. Psychomotor activity (PMA)
Increased / decreased / restless / agitated / destructive / self-injurious / aggressive
Abnormal involuntary movements-tics / tremors / akathisia
Catatonic signs rigidity / posturing / stereotypy/ echopraxia / waxy flexibility / negativism /
ambitendency / automatic obedience
6. Hallucinatory behaviour
II. SPEECH
Present/absent
Spontaneous/non spontaneous
Reaction time increased/decreased/normal
Relevant/irrelevant
Coherent/incoherent
Excessively loud/abnormally soft/monotonous
Rate of production low speech/poverty of speech/mutism/rapid speech/pressure of speech
Presence of stuttering / stammering/slurring whispering/muttering/echolalia/neologism (Give
samples of patients speech)
III. THOUGHT
Stream of thought
Decreased rate with increased pauses/poverty of thought/thought block
Form of thought
Content of thought
Any preoccupations
Obsessions
Phobias
Overvalued ideas and delusions of
persecution/reference/grandeur/love/jealousy/guilt/nihilism/somatic or
hypochondriac/worthlessness/helplessness/hopelessness/suicidal ideations
Delusion of control, thought insertion/thought withdrawal / thought broad casting
exalted /
4. Orientation
To time
To place
To person
5. Memory
Immediate retention & recall (Same as the digit span test to assess attention)
Recent memory (Ask how did the patient come to the hospital/what he ate for dinner the day
before or for breakfast / Give an address to be memorized & ask him to recall 15 min. later at
the end of the interview)
Remote memory (Ask for date and place of marriage, name & birthday of children, year of
passing S.S.L.C. examination etc.)
6. Intelligence
7. Judgment
Personal judgment (Ask about his/her personal expectations, plans and attitudes & assess
whether these are realistic)
Test judgment (ask for course of action in imaginary test situations fire test, letter test)
Social judgment (assess patients interaction patterns with other individuals & other
interviewer)
8. Insight
C. PHYSICAL EXAMINATION
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D. INVESTIGATIONS
DIAGNOSTIC FORMULATION
1ST
PROVISIONAL DIAGNOSIS
NURSING DIAGNOSES
Ward
Age
Unit
Sex
Hosp No.:
Address
DOA
Diagnosis:
Language spoken
Session No
Date
Time
Nonverbal
responses
Patient
Verbatim
Feelings of the
nurses/student
Nonverbal
responses
Inference
Evaluation
Issues / concerns identified
Themes
:
Effectiveness of interaction in relation to goals:
Plan for follow up interaction
:
Signature of the nurse/student
Speech
Thought
Perception
Cognitive functions
9. Physical Examination
10. Investigations
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