A) Psychiatric History

1) Demographic
- Name :
- Age :
- Gender :
- Race :
- Address :
- Date of Admission :
- Mode of Admission :
- Time of Admission :
- Informant(s) :
2) Chief Complaint

3) HOPI

4) Medical ROS
a) CVS -
b) Respiratory -
c) GIT -
d) MSK -
e) CNS -
f) Endocrine –

5) Past Psychiatric History

6) Past Medical and Surgical History

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7) Current Medications

8) Drug Allergy

9) Family History (Draw Family Tree)

10) Psychosocial History

a) Past
- Birth History
- Immunisation History
- Developmental Milestones
- Behaviour during Primary, Secondary and Tertiary Education
- Working Life
- Forensic History

b) Current
1) Place of Stay
2) Financial Support
3) Work

11) Sexual History

12) Substance Use History

a) Alcohol
b) Smoking
c) Drugs

13) Pre-morbid Personality

- Describe Type of Personality
- Coping Mechanism (e.g Hobbies)

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B) Mental State Examination (MSE)
1) General Appearance and Behaviour
a) General
- Patient physical age correspond to chronological age? (Yes or No)
- Alertness ( Alert, Drowsy, Stupor, Comatose)
- Build ( Frail, Cachectic, Thin, Medium, Muscular, Obese)
- Grooming ( Clean, Dirty, Fragrant, Smelly, Appropriate Dressing , Inappropriate
Dressing)
- Manner (Inappropriately Familiar, Seductive, Cooperative, Guarded, Glib, Angry)
- Posture (Rigid, Slouched, Comfortable, Threatening)

b) Face
- Attentiveness to Examiner (Bored, Internally Pre-occupied, Distractible, Attentive)
- Eye Contact (Yes , No)
- Emotional Facial Expression (Crying, Screaming, Tremulous, Perspiring, Calm)

c) Body
- Agitation (Yes , No)
- Abnormal Movement (EPS, Mannerisms, Stereotypies)
- Catatonia (Rigidity, Posturing, Waxy Flexibility, Negativism, Cataplexy,
Pseudo parkinsonism)

2) Speech
- Rate (Slow, Normal, Rapid, Pressured)
- Rhythm (Monotonous, Stuttering, Normal)
- Volume (Loud, Normal, Soft, Whispered)
- Amount (Mute, Reduced, Normal, Hyper talkative)
- Articulation (Clear, Mumbled, Slurred)
- Relevance (Yes , No)
3) Mood and Affect
a) Mood (Good, Normal , Low, Sad)
b) Affect
- Type (Dysphoria, Euthymic, Euphoria)
- Intensity ( Flat, Blunt, Normal, Exaggerated)
- Range (Constricted, Full)
- Appropriateness (Yes or No)
- Stability (Fixed, Stable, Labile)
4) Perception
a) Hallucinations (Olfactory, Visual, Auditory, Gustatory, Tactile)
b) Illusions, Depersonalisations, Derealisations, Déjà vu, Jamais Vu

5) Thought
- Flow (Thought Block, Reduced, Normal, Rapid)
- Content (Delusions, Overvalued Ideas, Obsessions)
- Form (Loosening of Associations, Flight of Ideas, Neologisms)

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 - Possession (Thought Insertion, Thought Withdrawal, Thought Broadcasting)
6) Cognition
a) Orientation (Tick if orientated)
- Time (Is it morning or is it night time?)
- Place (Where are you now?)
- Person (Who is that? Who am I?)
b) Attention and Concentration
- Serial Subtraction Test (Serial 7 Normal = 120 seconds , Serial 5 Normal = 60
seconds, Serial 1 Normal = 15 seconds)
- Days of the weeks and months (Forwards = Start from Tuesday count until reach
the next Tuesday) (Backwards = Start from Thursday count backwards until reach
the last Thursday)
c) Memory
- Immediate Memory = Digit Span Test (Forward Normal = 7 +/- 2 , Backward
Normal = 5 +/- 2)
- Recent Memory (1st Script = Gajah, Timun, Merah , Api, Pokok) (2nd Script =
Kereta, Epal, Kuning, Hujan, Nasi)
- Long-Term Memory (Address, IC)
d) Information and Intelligence
- General Knowledge (Who is the PM? What is the Capital of MY? What is the
Capital of Sarawak?)
- Arithmetic (28+5 =33 ; 50-28 = 22 ; 8x9 =72 ; 20/4 = 5)
e) Abstract Thinking
- Test of Similarity (Epal & Durian = Fruits ; Kapal & Kereta = MV ; Sawi &
Kangkung = Vegetables)
- Test of Differences (Ayam , Kuching, Pokok ; Hijau, Merah, Sedih)
- Proverb Test (Sikit sikit lama lama jadi bukit ; Katak di bawah tempurung ; Bagai
aur dengan tebing)
f) Judgement
- Social Judgement (Kamu rasa boleh ke pergi ke pasar tanpa baju seluar?)
- Text Judgement (Jika hospital tangkap api, apa yang kamu akan buat?)
- Personal Judgement (Future Plans)
7) Insight (<1/3 = No Insight, 2/3 = Partial Insight , 3/3 = Full Insight)
- Awareness
- Attribution
- Do you need treatment?