HISTORY OF PATIENT

I. Sociodemographic Data

NAME Dr. Kareena

AGE 44 Years
SEX Female
WARD NO
EDUCATION PHD
OCCUPATION Teacher
FAMILY MONTHLY INCOME 3 LAKHS
MARITAL STATUS MARRIED
RELIGION HINDU
LANGUAGE HINDI, ENGLISH
ADDRESS

HOSPITAL REG No.

WARD
BED No.
DATE OF ADMISSION
FINAL DIAGNOSIS Three key symptoms (low mood, loss of
interest, low energy) of depression were
present from last three months.
II. Informants:
Informant’s Name: Rahul
Reliablity of the informant: Husband
III. Chief Complaints

 CHIEF COMPLAINTS :

A) According to Patient: She stated that she had daily weeping spells, anxiety, restlessness,
fatigue and low mood. She reported that her sleeping was disturbed because it took her
several hours to fall asleep. She was experiencing these symptoms from last three months
B) According to Relative: Weeping spells, anxiety, restlessness, low mood.

IV. History of present illness

A 44 years old female visited a psychiatric clinic with symptoms of depression. She stated that
she had daily
weeping spells, anxiety, restlessness, fatigue and low mood. She reported that her sleeping was
disturbed
because it took her several hours to fall asleep. She was experiencing these symptoms from last
three months

DURATION : 3 months
MODE OF ONSET : Abrupt
COURSE : Continuous
PRECIPITATING FACTORS:

V. Past History
A) Past Psychiatric History:
Hospitalization: Patient was suffering from Hypertension from last 2 years and
Hypercholesterolemia from last 1 year.
Treatment taken: She was using Inderal (Propranolol) 40mg from last 2 years and Lipiget
(Atorvastatin) 10mg from last 1 year.
 Previous episode of the presenting complaints & past H/O substance abuse:

B) Past medical & Surgical history

 Hospitalization:
 Significant illness, both past & current: Medical/neurological/surgical

C ) Legal History

VI. TREATMENT HISTORY

DRUG DOSE ROUTE TIME ACTION
Lipiget
Inderal

VII. Family history

 Family Structure:
 Family History of Illness :
 Current social situation:
Socioeconomic status
Head of family-nominal & functional
Current attitude of the family members towards the patient’s illness.
Communication pattern in family
Social support system available
 GENETIC DIAGRAM :

VIII. Personal History

(A) PERINATAL HISTORY:

Antenatal history:
 Intranatal history:
 Type of delivery:
 Any complication:

Birth: Birth cry, Birth defects:

Postnatal complications:

(B) CHILDHOOD HISTORY:

Primary caregiver: Mother

Feeding: Mother
Age of weaning: 7 months
Developmental milestones:
Behavior and emotional problems: NONE
Illness during childhood: None
(C) EDUCATIONAL HISTORY:

Age of beginning of formal education: 3 years

Academic performance: Good
Relationship with peers and teachers: Good
School phobia: NO
Conduct disorder: No
(D) PLAY HISTORY:
Games played (at what stage and with whom): Cricket
Relationship with playmates: Good
(E) EMOTIONAL PROBLEMS DURING ADOLESCENCE:
Running away from home/delinquency/smoking/drug taking/any other: No
(F) PUBERTY:
Age at appearance of secondary sexual characteristic: 16
Age of menarche: 14 years
Regularity of cycle: 28days
Reaction to menarche: no
(G) OCCUPATIONAL HISTORY:
 Age at starting work: 24years
  Jobs held in chronological order: Teacher
 Current job satisfaction: Good
 Whether job is appropriate to client’s background: Yes

(H) OBSTETRICAL HISTORY:

 Last menstrual period:10 Days
 Number of children: 2
 Any miscarriage, abortion/ still births: none
(I) SEXUAL AND MARITAL HISTORY:
 Type of marriage: Love
 Duration of marriage: 20 years
 Details of spouse: Rahul
 Responsibilities shared between spouses: all

IX.PREMORBID PERSONALITY:
 Interpersonal relationships: Good
 Family and social relationships: Good
 Use of leisure time: Reading novels
 Predominant mood:
 Usual reaction to stressful events: Panic
 Attitude to self and others: Good
 Attitude to work and responsibility: Good
 Fantasy like: daydreams & frequency and content: none
 Habits: Reading novels
 Eating pattern: 3 times
 Elimination:
 Sleep: 8 hours
 Use of drugs, tobacco, alcohol: no