The document provides guidelines for conducting a psychiatric assessment, including sections to document a patient's demographic information, chief complaints, psychiatric history, treatment history, past medical and psychiatric history, family history, personal history including developmental, educational, occupational, sexual and marital details, and premorbid personality. The assessment aims to build a comprehensive picture of the patient and their condition.

1. By- Ms. Snehal Kapadiya
M.Sc (N)
Mental Health Nursing

2. I. Demographic data
 Name
 Age
 Sex
 Marital status
 Religion
 Occupation
 Socio-economic status
 Informant
 Address
 Information (relevant or not), adequate or not

3. II. Presenting chief complaints
(chief complaints/ present complaints)
 In patients own word and in infomant’s own word.
Eg., sleeplessness × 3 weeks
 Loss of appetite and hearing voice × 3
weeks
 talking to self × 3 weeks

4. III. Present psychiatric history
(history of present illness)
 Duration (days, week, months, year)
 Intensity- same/increasing or decreasing
 Mode of onset- acute (within few hours)
 sub acute (within few weeks)
 chronic (within few years)
 Precipitating factors- yes/no, if yes explain
 History of current episode- (explain in detail regarding the
present complaints)
 Associated disturbance- include present medical problems
 Eg., disturbance in sleep, appetite, IPR, social functioning and occupation.

5. IV. Treatment History
 Drugs: (name of the drug, dose, route, side-effect)
 ECT :
 Psychotherapy:
 Pharmacotherapy:
 Rehabilitation:

6. V. Past psychiatric and
medical history
 Number of episode with onset & course
 Complete or incomplete remission
 Duration of each episode
 Treatment details & its side effects if any
 Treatment outcomes
 Detail if any precipitating factors if present
 Substance use detail
 Surgical procedure/ accidents/ head injury/
convulsions/ unconsciousness/ DM/ HTN/ CAD/
Venereal disease/ HIV positivity/ any other

7. VI. Family History
 Family genogram – 3 generations include
onlygrandparents.
 But if there is a family history include the particular
 generation

8. VII. Personal History
a) Perinatal history –
 Antenatal period: maternal infections/
exposure to radiation/ any other
 Intranatal period: type of delivery- normal/
instrumental/ CS
 -Breath & cried at birth
 - Birth defects

9.  Postnatal complications: cyanosis/ convulsion/
jaundice / neonatal infection/ any other
 Mile Stones: - Normal or delayed

10. B) Childhood history
 Primary caregiver
 Feeding: breast feed/ artificial mode of feeding
 Age at weaning
 Developmental milestones

11.  Behaviour during childhood:
- Excessive temper tantrums
- Thumb sucking
- Stuttering OR stammering
- Feeding habit
- Head banging
- Neurotic symptoms
- Pica
- Enuresis
- morbid fears
- Night terrors
- somnambulism
- Habit disorders
- Excretory disorders etc.

12.  Illness during childhood:
-specifically for CNS infections
-epilepsy
- neurotic disorders
- malnutrition

13. C) Educational history
 Age at beginning of formal education:
 Academic performance:
 Extracurricular achievement:
 Relationship with peers and teachers:
 School phobia:
 Look for conduct disorder: eg. Stealing
 Reason for terminating studies

14. D) Play history
 Games played:
 Relationship with playmates:
E) Emotional problems during Adolescence
 Running away from home
 Delinquency
 Smoking
 Drug abuse
 Any other

15. F) Puberty
 Age at appearance of secondary sexual characteristics
 Anxiety related puberty changes
 Age at menarche (in females)
 Reaction to menarche
 Cycle regularities, duration of flow
 Abnormalities if any

16. G) Obstetrical history
 LMP
 Number of children
 Abnormalities associated with pregnancy, delivery,
puerperium:
 Termination of pregnancy if any
 Menopause (including any associated problems)

17.  H) Occupational history
- Age of joining job
- Job hold in chronological order
- Any changes in the job – if any, give
reason
- Current job satisfaction
*(Relationship with superiors,
subordinates & colleagues)
- Reasons for changing jobs
- Whether job is appropriate to
patient’s background

18. I) Sexual and marital history
 Genogram

19. EXAMPLE:

21.  Type of marriage
 Duration of marriage
 Interpersonal and sexual relationship: satisfactory or
unsatisfactory
 Extramarital relation if any

22. VIII. Premorbid Personality
(Personality of a patient consists of those
habitual attitudes & patterns of behaviour
which characterize an individual.
Personality sometimes changes after the
onset of an illness. Get a description of the
personality before the onset of the illness.
Aim to build up a picture of the individual,
not a type. Enquire with respect to the
following areas)

23. 1. Attitude to others in social, family & sexual
relationship:
 Ability to trust other, make & sustain relationship,
anxious or secure, leader or follower, participation,
responsibility, capacity to make decision, dominant or
submissive, friendly or emotionally cold, etc. difficulty
in role taking – gender, sexual, familial.
2. Attitudes to self:
 Egocentric, selfish, indulgent, dramatizing, critical,
depreciatory, over concerned, self conscious,
satisfaction or dissatisfaction with work. Attitudes
towards health & bodily functions. Attitudes to past
achievements & failure, & to the future.

24.  3. Moral & religious attitudes & standards:
 Evidence of rigidity or compliance, permissiveness or over
consciousness, conformity, or rebellion. Enquire
specifically about religious beliefs.
 4. Mood:
 Enquire about stability of mood, mood swing, whether
anxious, irritable; worrying or tense. Whether lively or
gloomy. Ability to express & control feelings or anger,
anxiety, or depression.
 5. Leisure activities & hobbies:
 Interest in reading, play, music, movies etc. enquire about
creative ability. Whether leisure time is spent along or with
friends. Is the circle of friend large or small?

25.  6. Fantasy life:
 Enquire about content of day dreams & dreams.
Amount of time spent in day dreaming.
 7. Reaction pattern to stress:
 Ability to tolerate frustrations, losses,
disappointments, & circumstances arousing anger,
anxiety or depression. Evidence for the excessive use of
particular defense mechanism such as denial,
rationalization, projection, etc.

26.  8. Habits:
 Eating pattern: regular/ irregular
 Elimination: regular/ irregular
 Sleep: regular/ irregular
 Use of drugs, tobacco, alcohol: yes or no, if yes give
details.