Psychiatric Clerking Sheet

NAME:

IC NO/RN:

DATE:

CHIEF COMPLAINT
(in complainant’s own words)

HISTORY OF PRESENT ILLNESS

Low mood
Loss of interest/anhedonia
Sleep disturbance
Change in appe<te
Change in weight
Feeling worthlessness/guilt
Reduced ability to focus
Suicidal thought/a@empt/self-harm

Hypomania/ Manic episode

Delusion
Hallucina<on

Feeling fearful/ anxious

Func<onal capacity

Stressor

Treatment from other sources

PAST PSYCHIATRY HISTORY

Onset & nature of symptoms

Perinatal depression/psychosis (for

female)

Any self-harm episodes/suicide a@empts

Treatment received
Treatment response/side effects
Reason for non-adherence
No. of hospitaliza<ons (last
admission/which hospital/reason for
admission)

FAMILY HISTORY & GENOGRAM

(FAMILY TREE)
Quality of family rela<onships in
genogram

Psychiatric illness in family

FHx of suicide/substance misuse

CHILDHOOD HISTORY (describe your

childhood)
Significant life events during childhood

ACADEMIC ACHIEVEMENTS
Secondary(PMR result, SPM result)

Highest Qualifica<on

Problems in school
(Truancy/Bullying/Substance/)

WORK HISTORY
List of jobs

Reason for change

Salaries

PSYCHOSEXUAL HISTORY
If relevant
MARITAL & RELATIONSHIP HISTORY

SOCIAL HISTORY

SUBSTANCE USE HISTORY (if

applicable)
(SMOKING/DRUGS/ALCOHOL)
Dura<on of use

Frequency/amount

Last use

Withdrawals/craving

A@empts to stop

Treatment centres

FORENSIC HISTORY
(IMPRISONMENT)

PREMORBID PERSONALITY
If I were to ask your friends or family to
describe you, how would they describe
you?

MENTAL STATE EXAMINATION

GENERAL APPEARANCE &
BEHAVIOUR
Dressing/Make up/Grooming
Coopera<on/Rapport
Unusual movements/restlessness
Body language/posturing
Signs of physical illness

SPEECH(PRODUCTION)
Ar<cula<on, pitch, volume, rate
Spontaneity, amount
Relevance, coherence
Pressure/circumstan<ality
Persevera<on

MOOD(SUBJECTIVE)
Ela<on/depression/anxious
AFFECT
Nature
Appropriateness/congruence to thought
Range( restricted/blunted/wide)
Stable/labile
Intensity/depth

PERCEPTUAL ABNORMALITIES
Sensory abnormality
Hallucina<ons
Derealiza<on/depersonaliza<on

THOUGHT(FORM)
Looseness of associa<on, concrete
thinking
Flight of ideas, racing thoughts

THOUGHT( CONTENT& POSSESSION)

Delusions/ideas of reference
Obsessions/phobias
Suicidal thoughts/intent
Homicidal thought/intent
Thought
inser<on/withdrawal/broadcas<ng

COGNITIVE FUNCTION
(Proceed if applicable; If not proceed
to Judgment)
OrientaSon
Time/place/person

ATenSon & concentraSon

Serial sevens/digit span
Spell a word forward & backward
Memory
Immediate
5 minutes recall
remote

CalculaSon/General Knowledge
Est. of level of intelligence

Abstract reasoning
Proverbs
Similari<es
Judgment
Insight
Awareness of symptoms
Symptoms as abnormal
Indica<ve of underlying illness
Need for treatment
PHYSICAL EXAMINATION
Height
Weight
Waist Circumeference
Blood Pressure
Pulse Rate
Relevant Examina<on:
Marks of deliberate self-harm:
Upper Limb (Right)
Upper Limb (Le_)
Lower Limb (Right)
Lower Limb (Le_)

INVESTIGATIONS ORDERED
(If relevant)

DIAGNOSIS
(with severity)

DIFFERENTIAL DIAGNOSIS

PLAN FOR MANAGEMENT

Bio/psycho/social/spiritual framework
Non-pharmacology
(Suppor<ve psycotherapy, OT, counselor)
Pharmacology
Follow up appointment and dura<on

SIGNATURE OF DOCTOR

NAME OF DOCTOR