PSYCHIATRIC HISTORY

Purpose: To obtain data from multiple sources (e.g., client, family, friends, police, mental health
personnel) as a means of identifying patterns of functioning that are healthy, as well as patterns
that create problems in the client’s everyday life.

Date: March 23, 2022

1. Demographic Information
Client Name : No data (Alias) No data Age: 18 years old Sex: Female Religion: No data
Residential Address: No data
Education: Senior High School
Ethnicity: No data
Partner Status: Single
Occupation: Student
Number of Children: Three (3)
Living Circumstances: No data
Identification mark: No data
Source of referral: No data
Date of Admission: March 23, 2022

2. Components of psychiatric history.

1. Chief complaint: main reason client is seeking psychiatric help.
✔ The client complaints of having lack of sleep, irritability, and excessive happiness, as well
as irrelevant and heightened anxiety.

2. Presenting symptoms: onset and development of symptoms or problems.

Note: Patient’s version
Informant’s version
✔ Client’s version: Client is not willing to participate in the social activities conducted in the
service.
✔ Informants version: Client is unable to perform self-care due to low energy level arising
from depression.

3. History of present illness(HOPI)

✔ Client was an active child and there is no major and behavior problems during childhood.
✔ When the client was started to complaints of lack of sleep and irritability when she was
18 years old.
Predisposing factor:
✔ The client is scared to receive low grades in her 11th grade board exam.

4. Past psychiatric and medical history

✔ Client has a history of catatonia
✔ Client was not receiving regular treatment and follow-up, and as a result, she began to
exhibit symptoms such as sadness, inability to engage with her family, and inability to
carry out her daily duties (ADL).

5. Treatment history
✔ Client was undergoing treatment for two weeks and was recommended by the physician
to treatment should be continued for at least 3-4 months. She did, however, take
medication. She only used the medications for two weeks before stopping since she felt
normal.
✔ Client experienced the symptoms because of her noncompliance.
✔ Client underwent treatment such as psychopharmacotheraphy, electroconvulsive
theraphy and other psychotherapies.
✔ Client underwent treatment at MGMCRI in March 2019.
 6. Family history.
✔ The mother had a manic depressive illness or manic depression (Bipolar).
✔ The relationship between client and the family is sufficient.

7. Personality Profile
✔ Client is a introvert person and had trouble maintaining relationship with family and
friends.

8. Personal History and Developmental History

a. Childhood history: Client was an active child and there were no major behavior
problems during childhood.
b. Play History: No data
c. Puberty: No data
d. Education and Occupational history: Client started going to school at around 3 1/2
years old. She was an average student; she excels in science, but not in math.
e. Menstrual and Obstetrical history: No data
f’ Sexual and Marital history: No data
g. Perinatal history: No data
9. Premorbid history
a. Attitude to self and others: An introvert type of person had a hard time in maintaining
her relationship with family and friends, who’s also afraid of getting low grades and was a
drug noncompliant, thus, she withdrew herself.
b. Attitude to work and responsibility: Not willing to participate in social activities.
c. Religious beliefs: No data
d. Fantasy life- sexual fantasy/ day dreaming: No data
e. Habits: No data
10. Patient Management Problems (PMP ) assessment: No data
11. Alcohol & drug history: Client was drug non compliant.
12. Forensic history: No data

Informants:
– Patients mother/father/wife/husband/son/daughter •
– Patients file
– Patient self