CASE

HISTORY

I. IDENTIFYING DATA
§ Name § Occupation
§ Age § Religion
§ Sex § Marital Status
§ DOB § SES
§ Education § Contact details

II. RELIABILITY
§ Patient (Good, satisfactory, unsatisfactory)
§ Informant (Good, satisfactory, unsatisfactory)

III. REFERAL
§ Referred by
§ Referred for
§ Informant

IV. CHIEF COMPLAINTS
(Up to 5 points; chronological order, verbatim, in brackets mention duration of each, keep in
mind working diagnosis)

V. ONSET, COURSE, DURATION AND PROGRESS
§ Onset
Ø Abrupt (within last 12-48 hours)
Ø Acute (1-1 ½ weeks)
Ø Sub-acute (2 weeks)
Ø Insidious (1 month or more)

§ Course (continuous, episodic, fluctuating)
§ Duration
§ Progress (improving, deteriorating, static, fluctuating)
§ Predisposing factors
§ Precipitating factors
§ Perpetuating factors

VI. HISTORY OF PRESENT ILLNESS
i. Symptoms (list, nature/characteristics, duration, frequency, severity, functional analysis,
identifying circumstances, patient’s reaction, reaction of others)
ii. Distress (of patient and family; attitude of family members to illness)
iii. Dysfunction (daily life, social life, education/work life, personal, self confidence)
iv. Affect on biological functions (appetite, sleep, libido, sexual function, any habits picked
up like drinking, smoking, etc.)
v. Current treatment history, if any (medical (list medications), psychiatric, self-help,
mystical; effects, why stopped)
vi. 1-2 lines on symptomatology and why patient’s seeking treatment now

VII. NEGATIVE HISTORY
(disorders or symptoms not present)

VIII. PAST HISTORY
§ Past psychiatric illness (course, duration, nature, severity, patient’s response, treatment)
§ Medical history (past till present; medicines, dosage, surgery, trauma, known allergies,
immunization/vaccination, etc.)



 IX. FAMILY HISTORY
§ Family structure
§ Social status of family
§ Present living conditions (number of members, number of earning members, sharing of
responsibilities, environment)
§ Family medical history
§ Family mental history
§ Parental consanguinity
§ Authority figure
§ Parenting style
§ Attachment style
§ Important family events
§ Relationships with patient and between members (cordial, hostile)
§ Pattern of communication (close, open)
§ Boundaries
§ Cohesiveness
§ Family stressors (financial, loss of member, any event)

X. GENOGRAM

XI. PERSONAL HISTORY
1. Birth History
a. Prenatal (pregnancy, term, maternal infection, illness, stress, maternal use of
medication, drugs or alcohol, trauma, etc.)
b. Perinatal (gestational age at birth, labor duration, place of delivery (home,
hospital), delivery normal or c-sec, use of forceps, complications, fetal distress)
c. Postnatal
i. Birth cry (present or not present, immediate or delayed, spontaneous
or induced)
ii. APGAR
iii. Weight
iv. Infections
v. Birth defects
vi. Incubators
vii. Maternal separation/deprivation/neglect

2. Developmental History (detailed, for children)
a. Reflexes g. Standing with
b. Smiling support
c. Rolling h. Standing without
d. Control of neck support
e. Crawling i. Walking
f. Sitting without j. Toilet training
support k. Motor (fine, gross)

l. Psychomotor coordination (riding tricycle)
m. Feeding history
i. Breastfed till what age
ii. Age at which solid food introduced
n. Speech and language
i. Age (babbling, cooing, monosyllables)
ii. Verbal/nonverbal
iii. Expressive/receptive




 3. Childhood Problem Behaviors
a. Thumb sucking j. Delinquency
b. Bed-wetting k. Obstinacy
c. Night terrors l. Temper tantrums
d. Sleep walking m. Fits
e. Nail biting n. Eating inedible
f. Stammering items
g. Phobias o. Colic
h. School phobia p. Others
i. Truancy

4. Academic History
a. Age at which f. Extracurricular
started school activities, hobbies
b. Age at which left and sports
school (why, if g. Peer relations
dropped out) h. Teacher relations
c. Response to school i. Disciplinary action
d. Adjustment to j. If change in schools,
school environment and why
e. Academic
motivation and
performance

5. Occupational History
a. Job role, company, year, duration
b. Attitude towards work
c. If change in jobs, and why
d. Current and future plans

6. Pubertal History
a. Age at onset
b. General preparation for puberty
c. Regularity of cycle
d. Maintenance of hygiene
e. Changes in secondary sexual characteristics
f. Menopause (age, physiological discomfort, reaction)

7. Sexual History
a. Sex education and when?
b. Patient’s response
c. History of masturbation (age, etc.)
d. Age at first sexual activity
e. Heterosexual activity/homosexual activity
f. Consensual/non-consensual
g. Number of partners
h. Use of protections
i. History of STDs
j. Sexual deviance
k. Use of external aids (porn, medicine, physical aids)
l. Attitudes towards sex
m. Current sexual functioning

8. Marital History
a. Age at marriage
b. Duration of marriage
c. Consanguinity
 d. Love/arranged
e. Forced or prepared
f. Age of spouse at marriage
g. Occupation of spouse
h. Relationship (congenial, hostile)
i. Children living/abortions/stillbirths
j. Present family setup
k. Separation/divorce (when, why, duration, outcome)

9. Social History
a. Play history (SEE MORE ON THIS)
b. Friends
c. Social activities

10. Substance use
a. Age at first use, why
b. What substance, quantity
c. Response to substance when taken first time; experience pleasant or
unpleasant
d. Present usage, what, single or multiple, quantity
e. Frequency, need
f. Any particular time or situation
g. Alone or with group
h. If substance is culturally accepted
i. Effects
j. Problems because of abuse (physical, psychological, social, occupational)
k. Withdrawal symptoms
l. Source of funds for obtaining substance

XII. PREMORBID PERSONALITY
§ Attitudes towards self (positive, negative, optimism, confidence, esteem, problem
solving approach)
§ Attitudes towards others (nurturing, paranoid, etc.)
§ Attitudes towards work and responsibilities
§ Interpersonal Relationships (friends, family, colleagues, romantic)
§ Habits (diet, sleep, smoking, drinking, etc.)
§ Hobbies and interests
§ Leisure activities
§ General personality traits and characteristic traits (perfectionist, impulsive, sensitive,
controlling, etc.)
§ Predominant mood and emotions (anxious, despondent, optimistic, self-deprecating,
etc.)
§ Attitudes and standards (towards religion, moral, health and body)
§ Ultimate concern (who or what matters most in life)













 MSE

I. GENERAL APPEARANCE
§ Body built § Facial expression
§ Appearance (Tidiness) § Eye contact
§ Age appropriateness (old- § Alertness/Consciousness
looking/young-looking as per § Healthy/sickly
age) § Signs of anxiety
§ Clothes § Rapport (easily established,
§ Grooming (hair, nails, etc.) with difficulty, not
§ Posture/bearing established)

II. MOTOR BEHAVIOR
§ Purposeful § Agitated
§ Gait § Combative
§ Rocking § Retarded
§ Pacing § Hyperactive
§ Catatonias § Aimless
§ Dystonia § Awkward
§ Mannerisms § Destructive
§ Gestures § Self-injurious
§ Tics § Aggressive
§ Stereotypes § Restlessness
§ Tremors § Grimaces
§ Picking § Echopraxia/echokinesis (inv
§ Clumsy oluntary repetition or
§ Agile imitation of another
§ Limp person's actions)
§ Rigid

(For children comment upon ease of separation from caregiver, spontaneous activity and
joint attention)

III. ATTITUDE DURING INTERVIEW
§ Cooperative § Shy
§ Confident § Childish
§ Interested § Guarded
§ Attentive § Suspicious
§ Frank § Seductive
§ Playful § Defensive
§ Ingratiating § Attention-seeking
§ Uncooperative § Exhibitionistic
§ Evasive § Hostile
§ Inhibited

(For children comment upon reaction to clinician, separation from parent, reaction upon being
directed/redirected by caregiver/clinician)










 IV. VOICE & SPEECH
i. Intensity (audible, excessively loud, abnormally soft)
ii. Pitch (normal fluctuations, monotonous)
iii. Reaction time (normal, delayed)
iv. Speed (normal, rapid, slow, pressured)
v. Ease of speech (spontaneous, fluent, articulate, hesitant, mute, slurred, stuttering,
mumblings, mutterings, paucity)
vi. Tone (angry, pleading, monotonous, indifferent)
vii. Relevance (relevant, irrelevant)
viii. Coherence (coherent, incoherent)
ix. Goal Direction (goal directed, circumstantial, tangential)
x. Productivity (normal, overabundant, scant)
xi. Manner (relaxed, excessively formal, tensed, inappropriately familiar, disinterested)
xii. Echolalia
xiii. Clarity
xiv. Vocabulary
xv. Prosody (patterns of stress and intonation)
xvi. Idiosyncrasies and oddities in speech


(Child: comment on whether speech clarity, vocabulary, and grammar is age-appropriate: e.g. Pt. uses 3-word
sentences, 75% understandable; Fluency and clarity of speech can be affected by stuttering, cluttering, and
speech impediments.)

V. MOOD (a pervasive and sustained emotion that colors the the person’s perception of the world)
§ How do you feel right now? (depth, intensity, duration, fluctuations)
Ø Depressed Ø Guilty
Ø Despairing Ø Awed
Ø Irritable Ø Futile
Ø Anxious Ø Self-contemptuous
Ø Terrified Ø Anhedonic (inability to
Ø Angry feel pleasure
Ø Expansive Ø Alexithymic (inability to
Ø Euphoric identify and describe
Ø Empty emotions in self)

VI. AFFECT (outward expression of person’s inner experiences)
i. Range (normal, broad, restricted, blunted, flat, shallow)
ii. Appropriateness (appropriate, inappropriate, mood congruent, mood incongruent)
iii. Stable or labile
iv. Nature
o Anxious o Elated
o Panicky o Irritable
o Fearful o Enraged
o Depressed o Apathetic
o Euphoric

VII. PERCEPTION
§ Normal
§ Hallucinations (See things? Hear voices? Strange smells? Feel things?)
§ Illusions
§ Depersonalization (Detached from self?)
§ Derealization (Detached from environment/world?)
§ Mood congruency



 VIII. THOUGHT FORM/PROCESS
§ Productivity
Ø Overabundance of ideas
Ø Paucity of ideas
Ø Flight of ideas (thoughts move abruptly from one idea to another, often with
rapid, pressured speech)
Ø Rapid thinking
Ø Slow thinking
Ø Spontaneity

§ Continuity
Ø Rambling
Ø Derailment/loose associations (breakdown in logical connection between ideas
and overall sense of goal directedness)
Ø Circumstantiality (over-inclusion of trivial or irrelevant details that impede the
sense of getting to the point)
Ø Perseveration (repetition of out-of-context words, phrases or ideas)
Ø Tangeniality (in response to a question, the person gives a reply that is
appropriate to the general topic without actually answering the question; e.g.:
Have you had any trouble sleeping lately? I usually sleep on my bed but now I
sleep on my sofa).
Ø Thought blocking (sudden disruption of thought or break in flow of ideas)
Ø Clang associations (thoughts are associated by the sound of words rather than
meaning; thought rhyming)

IX. THOUGHT CONTENT
§ Preoccupations
Ø Obsessions Ø Suicidal
Ø Compulsions ideation
Ø Phobias

§ Delusions
Ø Do you feel people want to harm you? (Persecution)
Ø Do you think you have special powers? (Grandiosity)
Ø Do you think everyone knows what you’re thinking? (Broadcasting)
Ø Do you think someone is implanting thoughts in your head or that your
thoughts are not your own? (Insertion/Alienation)
Ø Guilt
§ Neologism (invention of new words or phrases or use of conventional words in
idiosyncratic ways)
§ Dreams (recurrent, nightmares)
§ Fantasies (recurrent, favorite)

X. SENSORIUM
1. Orientation
§ Person (What is your name? Do you know who I am?)
§ Place (Where are you right now? What place is this? Which city is this?)
§ Time (Date, day, month, year)
§ How long in hospital?

2. Attention
§ Level of Consciousness (responsiveness to stimuli)
§ Easily aroused and sustained
§ Easy to arouse but not sustain
§ Difficult to arouse and sustain
§ Difficult to arouse but sustained
§ Stupor
 § Lethargy
§ Fugue State

3. Concentration & Calculation
§ Count from 1 to 20
§ Serial 7 or (Starting from 100, count backward by 7)
§ Name the months of the year backwards.
§ Calculate 10+5, 3x4, 20-7
§ How many paise are there in 2 rupees?
§ If one pencil costs 2rs, how much with 3 pencils cost?

4. Memory
§ Immediate (Repeat after me: cat, apple, table; repeat digits forward/ backward:
1, 4, 9, 2, 5)
§ Recent (What did you eat for dinner last night? What did you have for breakfast
this morning?)
§ Remote (Where were you born? Where did you go to school? Date of marriage?
Birthdays of children?)

(Ask a child to name age-appropriate letters, spell, count to x, recite the days of the week, do simple math;
assess ability to classify, categorize (‘round fruits’).)

XI. INFORMATION & INTELLIGENCE
§ Name some vegetables/fruits/animals
§ What is the capital of XYZ?
§ Abstract reasoning
Ø Similarities
Ø Differences
Ø Proverbs

XII. JUDGEMENT
§ Personal (assessed by asking about personal situations or future plans. Do you take a bath
daily? Able to follow daily routine? Where do you see yourself in the next 5 years?)
§ Social (behavior towards others, social/work responsibilities. Do you go to school/work
daily? What else do you do in school? Do you take your children for outings? Do you like
meeting people?)
§ Test (assessed by evaluating reactions to situations. If you’re on the road and see a letter
with an address on it, what will you do? What will you do if your house catches fire?)

XIII. INSIGHT
(Why are you here? Do you think you have a problem? Do you need treatment?)

1. Complete denial of illness
2. Slight awareness of being sick and needing help but denying it at the same time
3. Awareness of being sick but blaming it on others, on external factors, on medical or
unknown organic factors
4. Awareness that illness is due to something unknown in the patient
5. Intellectual Insight (admission of illness and recognition that symptoms or failures in social
adjustment are due to irrational feelings or disturbances, without applying that
knowledge to future experiences)
6. True emotional insight (emotional awareness of the motives and feelings within, of the
underlying meaning of symptoms, openness to new ideas and concepts about self and the
important persons in his/her life, the awareness leads to changes in personality and future
behavior)