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Bio Data

 Name

 Age

 Gender

 Education

 Marital Status

 S/o, D/o, W/o

 Occupation

 Informant

 Address

 Phone Number

Source and Reason for Referral

 From where are you referred?

 Reason for admission?

Presenting Complains/ Problems

Presenting Complains Duration

 Complains reported by the client herself

 Complains reported by the informant

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History of Present Illness

 What symptoms did you come here for?

 How long have you had this problem?

 When did this situation first occur to you?

 How long ago was the treatment done?

 What were the symptoms at that time?

 What where your life circumstances when these symptoms first occur?

 How old are you?

 Has there been any change in life?

 By which doctor or hakeem back then the treatment done?

 What drugs were used?

 Overtime the intensity was felt to be decreased?

 Did your personality change after symptoms appeared?

 If there was any change, what was it?

 How long did the symptoms last?

 Is this problem fixed in between?

 When did the problem and associated symptoms occurred the second time?

 What changes occurred in life when the symptoms appeared for the second time?

 What were the circumstances when the symptoms appear for the second time?

 Any change that has occurred in life?

Medical History
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 What disease have your doctor diagnosed you with in the past?

 What type of medications have you taken in the past?

 Do you have any allergies to foods or medication?

 Do you have any medical problems have you ever been hospitalized?

 Do any of your family members have medical problems?

Birth History

 Mother’s age & health at the time of this pregnancy

 Was there any illness, injuries, bleeding, or any complication during this pregnancy?

 (If yes please describe:

________________________________________________________________________

___ Duration of pregnancy: ________________

 Emotional status during pregnancy: _________________

 Duration of labor: ________________

 Type of Delivery: Normal: _______ C-Section: _____ Vaginal: ______ Breech: _______

 Place of Birth: _______________

 1st Cry: Yes / No

 Breathing Problem: Yes / No

 Anoxia: Yes / No

 Baby weight at the time of birth: _______

 Jaundice: Yes / No

 Any Fever: Yes / No (if yes) ____________

 Birth Injury: Yes / No (if yes) ________

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 Congenital abnormalities: Yes / No (if yes) __________

 Any other illness:

______________________________________________________________

 Did your child had any sucking/ feeding difficulty Yes / No (if yes)

____________________

Developmental Milestones Achieving Age

Physical Millstones

Neck holding

Sitting

Crawling

Walking

Babbling

Speech (single word)

Two words speech

Talking (complete sentence)

Eating without help

Dressing without help

Taking bath without help

Bladder Bowl control

Menstrual History

 What was your age at your 1st periods?

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 After your 1st period, have you ever experienced a time interval of 3 or more months

when you did not have a menstrual period?

 [IF "YES": Was this one time only or more than once?]

 What is the pattern of your menstruation cycle?

 How many days you have periods?

 What are your feelings during the periods?

 Are you facing pain in any part of your body during menstruation?

 Do you take any medication for menstrual pain?

Early Childhood History

 Can you tell me the best event of your childhood?

 What thing were made you cherish?

 Who were very close to you in your childhood?

 What was your relationship with your friends?

 What were your hobbies?

 What type of game you liked to play in your childhood?

 What is your favorite dish?

 Can you tell me a bad event of your childhood memory?

 Did you ever fight with someone in your childhood?

Educational History

 When did you start going to school?

 How did you feel going to school for the first time?
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 How did you feel going to school for the first time?

 How were you in studies?

 What did your teachers think about you?

 What did you think about your teachers?

 How long did it take you to fit in at school?

 How was your relationship with your classmates? Had you ever changed you? If yes then

why and how many times?

 Have you ever failed a class?

 Your favorite subjects?

 What were your subjects in matric?

 Did you choose your subjects by your own choice in matric?

 Did you take admission in college?

 Can you explain about your college life?

 Why did you stop studying?

 Have you ever participated in extracurricular activities?

 If yes, then explain what type of activities?

 Did you ever get bullied by your school or college mates?

Occupational History

 When did you start your 1st job?

 Which type of job it was?

 Are you still doing job?

 How much satisfied with your job?

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 If no, then ask why?

 How is your relationship with your boss?

 How is your relationship with your colleagues?

Religious Orientation

 Where do you place yourself on a scale of 10 regarding religious orientation?

 How much regular are you in performing religious duties?

Marital/ Sexual History

 At what age did you notice physical changes?

 Did you know about menstruation before?

 When did you start menstruating?

 What did you feel about your physical changes?

 What kind of changes in mood are seen after adulthood? Anger or irritability?

 Has there been any kind of change in your feelings or emotions?

 Were you touched in a wrong way as a child or young that you felt bad about?

 (if yes) Did you tell anyone about this?

 Has there been any change in your mood after this incident?

 How many friends do you have?

 Are there boys and girls among these friends?

 Is there any close friend with whom you have an emotional connection?

 What kind of relationship do you have with this friend?

 Do you go out with him/ her?

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 Does this friend visit your house?

 Did that friend ever stay the night?

 Is it friendship or liking?

 Have you ever expressed this liking?

 Are these relationships important?

 How long did the relationship last?

 How did those relationships end?

 How did you feel at the end of these relationships?

 Are you married?

 How is your relationship with your spouse?

 What do you feel about your spouse

 How is your married life?

 How long have you been married?

 How do you improve your marriage?

 Do you have any child?

 How many children do you have?

Drug Use

 Have you ever taken painkillers without the prescription of doctor?

 Have you ever used sedatives?

 Have you ever tried any drug?

 If yes
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 Then how much amount you were intake at once?

 When were you started intake of drugs?

 Why did you intake drugs for the first time? and how?

 After intake, how did you feel?

 Do you know the disadvantages of drugs use?

 Does it affect your daily life activities and your relationships?

 Does your family know about this?

 What are the benefits and harms you get from drugs usage?

 Do you want to quit drugs Use?

Forensic History

 Have you ever faced any legal problems?

 If yes, what kind of?

Pre-morbid Personality

 Before the illness, how was your thinking pattern?

 Before the illness, how was your behavior (sad, happy etc)?

 Does your behavior/ mood changes gradually or not before illness?

 Before the illness, you like to socialize with people or were you isolated?

 Did you make friends easily?

 How many friends did you have?

 How was your relationship with your friend?

 How much time did you spend with your friend?

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 What did people think of you?

 What kind of person did you consider yourself to be?

 How did you spend your free time?

 When you faced a problem, how did you solve it?

 Did you enjoy going out before your illness?

 When you used to angry, what did you do to control it?

 According to you, what are the flaws in you?

Family History

Father

 Is your father alive?

 If he is alive, what’s his age?

 What is your father education?

 What does your father do?

 How is their behavior?

 How’s his attitude/behavior with his siblings?

 His behavior with his father?

 Does your father have any mental or physical illness? If yes, what? What’s its nature?

Did he get any treatment or not?

 If the father has passed away, then in what year did he die?

 Cause of death, age at time of death?

 How long did it take to get over the shock of the death?
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Mother

 Is your mother alive?

 If she is alive, what’s her age?

 What is your mother education?

 What does your mother do?

 How is their behavior?

 How’s her attitude/behavior with his siblings?

 Her behavior with her parents?

 Does your mother have any mental or physical illness? If yes, what? What’s its nature?

Did she get any treatment or not?

 If the mother has passed away, then in what year did she die?

 Cause of death, age at time of death?

 How long did it take to get over the shock of the death?

Siblings

 How many siblings do you have?

 How old are your siblings?

 Age of your siblings and what they do?

 How is the attitude of siblings towards you?

 Do they have any mental or physical illness?

 Has any sibling passed away? If yes, when and how? At what age?

 What was your reaction to the death?

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 Does anyone in your family have any mental or physical problem?

General Home Atmosphere/ Environment

 How is the home environment practically?

 How many people live in the house?

 How is your household environment?

 Who makes the big household decisions?

 Do all members of the house spend time together?

 Have a meal together sometime? Do you go somewhere together?

 Do you all listen to each other’s problems? Are these problems solved together?

Case Formulation

Predisposing Factors

 Genetics

 Family History

 Childhood Experiences

Precipitating Factors

 Stressors/ Events (negative/positive)

 Like conflicts about identity, relationship conflicts

Perpetuating Factors

 Conditions that exacerbate rather than solve the problem

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 Like unaddressed relationship conflicts lack of education, financial stresses, occupation

stress etc.

Protective Factors

 Patient’s own areas of competency (Skills, talents, interest)

 Like wife supportive, educated, motivated

Informal Psychological Assessment

General Appearance and Behavioral Observation:

Speech

Form of Speech

Content of Speech

Mood

 Subjective
 Objective

Thoughts

 Content
 Form

Perception

 Visual perceptual
 Auditory Perceptual

Language Assessment

 Receptive Speech
 Expressive Speech

Gross motor skills

Fine motor skills

Cognitive Assessmemor
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 General Fund of Knowledge

 Comprehension and Vocabulary
 Abstract Reasoning
 Short term memory
 Long term memory

Orientation

 Time
 Person
 Place
 Insight

Formal Psychological Assessment

1. Intellectual Assessment

Otis Quick Scoring Mental Ability Test (Otis)

2.Personality Assessment

Rotter’s Incomplete Sentences Blank (Rotter)

3.Trait-Specific Assessment

 The) Beck Hopelessness scale (Beck)

 The Beck Depression Inventory (Beck)

Intellectual Assessment

Qualitative Analysis:

 Family attitude:
 Social and sexual attitudes:
 General attitude:
 Character traits:

Identification of problem/Diagnosis

 Diagnosis according DSM5 criteria

 After identify symptoms
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