PERSONAL PSYCHIATRIC HISTORY AND CASE FORMULATION

PART I: Introduction: Identifying data and a pip into her psychiatric/ medical history

1. Identifying data : Name, age, marital status, occupation address, specific and current living
circumstances
2. Chief complaint
3. Present illness
4. Past Illness: psychiatric, medical, substance use

Part II: PERSONAL HISTORY (ANAMNESIS):

Pre-natal – pre-natal care, illness of mother if any, wanted vs unwanted pregnancy, family reaction
Early childhood -0-3 years old- quality of maternal interactions during feeding, relationships with yaya,
mother and other significant persons; toilet training, sibling rivalry, early fantasies and dreams.

Middle childhood- 3-11 years old- gender identification, type of punishment at home, people who
provide discipline and influence early moral values formation.
School experiences, peer relationship and role models.

Late childhood – puberty- reaction to development/ appearance of sexual development

Adolescent years- most turbulent years; showing signs of independence from parents through peer
groups, hero worshipping, idealized groups, history of truancy, juvenile actuations.

Early adulthood- intimate boy-girl relationships, significant affairs, occupational history, living conditions,
etc

Part III. Review of Systems

Part IV: Family history, fantasies, dreams, family value systems
Part V: Physical Examination and mental status examination

Part VI: Case Formulation

- Be able to integrate the child rearing practices done by your care giver and how it has affected you in
your personality development.
- Discuss personality development theories which have influenced your outlook in life.