HISTORY TAKING PROFORMA

1. Identification data.
2. Informant, his relationship with patient and its reliability (in case of more than
one informant, give information of each separately).
3. Complaints (reason of consultation) with duration.
4. History of present illness.
5. Past history- Medical and mental or psychological in detail.
6. Family History- Father, mother, siblings- age, health, occupation, personality,
consanguineous marriage, marital condition of sibs if any. Draw a family tree
including still births, social position and status of family. Interaction and
emotional relationship between them, general atmosphere of home. Any chronic
medical family history. Psychiatric illness with duration.
7. Personal history-
I. Parental and Birth- Mother during pregnancy, normal delivery or not,
breast fed or not, wanted child or not.
II. Early development- General build, milestone.
III. Neurotic traits- Night terrors, sleep walking, temper tantrum, bed
wetting, thumb sucking, nail biting, food fads, stammering, mannerisms,
fear states etc. give example if possible and duration of each.
IV. Childhood- Illness if any, growth after that, relation with relatives and
friends.
V. School- Age of beginning and finishing, educational level reached,
hobbies, interests, relationship with teachers and classmates. School
phobia, delinquency.
VI. Menstrual history- Menarche, regularity, duration, pain, whether
prepared for the menarche.
VII. Occupation- Age of taking up first job, jobs held, if left, reason for
leaving, satisfaction of works, ambitions.
VIII. Marital history- Age at which married, arrange or not, how well know the
spouse, personality of spouse, compatibility, sexual satisfaction or not,
children and detailed about them, no. of abortions, no. of live births.
8. Premorbid Personality- Please do not use adjuctives and examples of each to
confirm the statement under following heads.
i. Social interpersonal relations with friends, relatives, workmates
ii. Intellectual activities- hobbies etc.
iii. Mood stable cheerful, optimistic etc.
iv. Attitude to work, responsibility, taking decisions etc.
v. Moral standards, attitude to religion, ambitions, pefectionistic, selfish,
suspicious.
vi. Energy or initiative to work.
vii. Fantasy life.
viii. Habits, addictions etc
9. Physical examination- Head to toe examination in detail.
10. Treatment- drug chart and ECT.
11. Mental Examination- Appearance & behavior, consciousness, orientation,
attention & concentration, memory, intelligence, affect, perception, thinking,
volition, judgment, insight.
12. Diagnostic Formulation- Summary with relevant, positive and negative points
from above 10 items, diagnosis, dynamic understanding of patient, high lighting
normal and or pathological coping mechanisms.
13. Suggested Management- Investigations (medical-psycho-social), interventions
(drugs with reasons for prescription. Other physical and psycho-social methods
or treatment.

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 MENTAL STATUS EXAMINATION
Nurses capacity to observe and describe the behavior accurately can provide valuabe
information about a patients mental status. Nursing staff should be thoroughly familiar with
the terms used to describe the behavior.
A. General Appearance:-
 Facial expressions:-
 Is it appropriate to and consistent with the subject under discussion?
 Did it change appropriately with the change of subject was the patients
face unexpressive and flat.
 Did he look to be normally attentive, apathetic or indifferent.
 Did the patient at any time show elation (mild pleasure) appropriate
smile or uncontrolled laughter, fear (mild anxiety) or
apprehension, crying or absolute terror or anger (frowning) rage
or fury, depressed or blank and vacant gaze.
 Posture:-
 Was the patient normally relaxed, stiff, or guarded.
 Did he adopt strange postures, which they are capable of maintaining
for long periods of time.
 Mannerisms repeated small movements of a habitual kind under stress e.g.
characteristic way of raising eye brows, tick like movements particularly
in the peri-oral area, shrugging of shoulders, repeated clearing of throat,
repeated blinking. In its extreme from it can be an elaborate strenuous
regular exercise.
 Dress:-Was the patient dressed with normal neatness. Were the clothes
appropriate to the season and the occasion.
 Hygiene:- Was the patient clean, was his hair combed, was his finger nails
cut.
 Physical Features:-
 look older or younger than his age.
 Underweight
 Physical deformity.
B. Motor Disturbances:-
a. Overactivity or hyperactivity:- This ranges from mild restlessness and an
inability to sit still or relax upto the ceaseless activity of some seriously ill
patients. e.g. acute manic reactions.
b. Underactivity or motor retardation:- A general slowing down of activity
level and bodily functions.
c. Stupor:- When retardation is progressive and severe and the patient may
finally reach stage where he is completely motionless. He is fully conscious,
but remains in one position for hours at a time.
d. Stereotype:- Is the constant repetition of any speech or action. It may also
occur in the form of writing a given word or phrase over and over again.
e. Compulsive movements or compulsion:- The patient feels compelled to
carryout a certain pattern of behavior, while knowing fully well that it is
 absurd and logically unnecessary yet finding no peace until he has completed
it.
f. Ecopraxia:- Is the pathological repetition by imitation of the movement of
another person. The patient may act as mirror image of physician and assume
his postures and gestures (is a characteristic of catatonic schizophrenia).
g. Negativism:- Patients failure to cooperate. It onsists of refusal or active
resistance to carry out even simplest request i.e. refusal for food and drink,
refusal to void or defecate. Sometimes he may even do the opposite of what
he is said. For e.g. lowering his hand when asked to raise it, push the spoon
into floor instead of putting it into his mouth.
h. Automatic obedience:- It appears the reverse of negativism in the patient
shows a pathological degree of compliance (evidenced in feasibility).
DISORDERS OF SPEECH (DISORDERS OF THOUGHT)
There are three aspects of disorders:-
 Disorders of form of thought
 Disorders of content of thought
 Disorders in rate of speech

I. DISORDERS OF FORM OF THOUGHT:-

a) Circumstantiality:- Patient includes in his conversation unnecessary details
and explanations before the goal is finally reached. The details expresses are
related but not essential.
b) Tangential Thinking:- It is same as circumstantiality except that the goal is
never reached.
c) Incoherence:- In which no sense can be extracted from his speech.
d) Irrelevant :- When the patient does not answer appropriately to the action.
e) Neologism :- Patient may invent his own language and use new words.
Arrange of new words usually by condensing several other words. Each
opinion has special meaning for the patient.
f) Word Salad:- Isolated, disconnected words mixed up in a hopeless jumble.
g) Persevration:- Is the involuntary and morbid repetition of a specific word or
idea which persists inspite of patients efforts to move on to new idea.
h) Ambivalence or Ambivalent Ideas:- When two contradictory ideas,
emotions, attitudes or wishes exist in the mind of patient and they are allowed
to exist without the rejection of either. It implies dual attitude of a person or
object (the attitudes being of opposite character).
Re-evaluation of Speech should include:
i. Intensity:- Was the patient’s voice normally audible, excessively loud.
ii. Pitch:- Was the voice monotonous or did it show any abnormal changes.
iii. Speed :- Did he speak at the usual rate of speed very slowly or rapidly.
iv. Spontaneity :- Was his speech spontaneous, did he respond only when questions
were put to him or was he mute.
v. Manner:- Was manner of speaking excessively formal, relaxed or inappropriately
familiar.
 vi. Reaction time:- Was it appropriate or abnormally slow.
II. DISORDERS IN THE CONTENT OF THOUGHT

a) Delusions :- Delusions are false fixed beliefs, which are irrational not shared by
persons of same race, age and standard of education, which is held by conviction and
which cannot be altered by logical arguments and which are persistent.
Systematized delusions:- When delusions are built up into a complex, elaborate and
more fixed structure.
Unsystematized delusions:- When they are fleeting and vague.

The various types of Delusions

i. Persecutory Delusions:- Delusional beliefs of an individual that he is being
deliberately interfered with, discriminated against, threatened or otherwise
mistreated.
ii. Delusions of Reference:- Delusional beliefs that either people are talking
about him referring to him or that remarks or action of people he meets are
intended to have some special significance for him.
iii. Delusions of Influence or Passivity :- Delusional beliefs of an individual that
enemies are influencing him in many ways and that his body, his thoughts and
his feelings are controlled by others.
iv. Delusions of Sin & Guilt:-Delusional beliefs of an individual that he has
committed some unforgivable sins or committed some wickedness in his past
life that have brought calamity to others and that is evil and worthless.
v. Hypochondrial Delusions (Delusions of Bodily Disease):- are those
delusions in which the patient holds a fixed conviction concerning the
presence of disease or abnormality in some part of his own body.
vi. Delusions of Grandeur:- Delusional beliefs of great power, wealth and
influence.
vii. Nihilistic Delusions:- Delusional beliefs that nothing exists, that the whole
world is destroyed or may be convinced that some fate has be fallen on one or
more of his relatives. He may also state that he is dead or that certain part of
his body and died or ceased to function.
It has two forms:-
A. Derealization
B. Depersonalization
A. Derealization:- when all the things in the environment are changed or
destroyed.
B. Depersonalization:- When the patient says that he himself is changed or
dead.
b) Obsessions :- Obsessions are fixed and recurring thoughts in the patients mind.
Patient himself recognize them to be abnormal. Ideas recur over and over again nd
forces themselves into consciousness even though unpleasant.
c) Phobia:- Phobia is morbid fear associated with morbid anxiety.
OR
It is an exaggerated and pathological dread of some specific type of stimulus or
situation and the person avoids the situation.
 d) Preoccupation:- When thought content centres around a particular idea and is
associated with strong affective tone.
e) Phantasy or Fantasy:-A product of imagination. It is a mental representation of a
scene or occurrence that is recognized as unreal but is either expected or hoped for.
There are two type of fantasy
A. Creative
B. Day Dreaming
A. Creative:- Which prepares for same later action.
B. Day Dreaming:- which is the refuge for wishes that can’t be fulfilled in
reality.

III. DISORDERS OF RATE OF SPEECH

a) Pressure of Speech:- Which the rate is accelerated.
the speech is valuable that it is difficult for the listener to interrupt (it may also be
precursor of flight of ideas). Seen in states of excitement and over-activity.
b) Flight of Ideas:- When pressure of talk is more severe, there is the tendency of
the patient to start talking on one subject and then switch to another and then to
another with little connection between them.
c) Retardation :- Slowing of speech.
d) Mutism:- The patient may not talk at all (the patient may be prevented from
speaking by feelings of marked anxiety, fear or hostility).
e) Aphonia:- Patient is able to speak only in whisper (neurotic patients use the
mechanism of conversion).
f) Thought Block:- The patients thought and speech are proceeding at an essentially
average rate but are very suddenly and completely interrupted in the middle of a
sentence, the gap may last for several seconds, even upto a minute after which the
patient resumes speaking either where he left off or on a completely new topic.
g) Clang Association:- It is an associative disturbances in which the patients may
follow one word with another and where the mere of a word rather than its
meaning touches a new thought (there is superficial resemblance of words) e.g.
one patient said my life is going with bang, bang, hang, you will hang if you don’t
watch out.
DISORDERS OF PERCEPTION
Perception:- An act or process of awareness resulting from the act of stimulus upon
the sense organs and an additional element coming from the past experience of the
individual.
a) Illusion:- It is defined as subjective perversion of an objective content.
(misinterpretation of the stimuli.)i.e. the subject himself puts wrong meaning to
the object.
b) Hallucination:- It may be defined as a sensory experience in the absence of
stimulus or an object.
Hallucinations may involve any of the sense
i. Auditory Hallucinations:- Involving the sense of hearing e.g. the patient
may hear some voices telling him what to do, communicating on or
criticizing his actions. The voices may take accusations, give commands,
 utter obsence words, and suggestions, threaten punishment or provide
reassurance.
ii. Visual Hallucinations:- The patient sees vision, usually of clearly
defined people of objects, but occasionally flashes of light or
representation of geometrical patterns and the accompanying emotion of
joy or terror.
iii. Olfactory Hallucinations:- Involving the sense of smell. The smell is
rarely pleasant one, much more commonly, it is said to be horrible.
iv. Gustatory Hallucinations:- Involving the sense of taste. It is not
complained of as such instead the patient states that his food has a
peculiar smell. Olfactory and gustatory are often found together in one
patient.
v. Tactile Hallucinations:- Involving the sense of touch e.g. crawling of
ants on the body.
vi. Hypnogogic Hallucinations:- False sensory perception occurring
including between falling asleep and being awake.
vii. Hypnopepnic Hallucination:- False sensory perception occurring
midway between sleep and awakening.
viii. Lilliputian Hallucination:- Perception of objects as reduced in size.
ix. Kinesthetic Hallucination:- False Perception of movement or sensation
as from an amputated limb (Phantom limb).
x. Macropsia:- State in which objects larger than they are.
xi. Micropsia:- State in which objects appear smaller than they are.
DISTURBANCES IN AFFECT
a) Inappropriate or incongruent affect:- Disharmony of affect and ideation.
b) Pleasurable affect:-
i. Euphoria:- First moderate level in the scale of pleasurable affect. It is feeling
of emotional and physical well being.
ii. Elation:- Second level of pleasurable affect. It is characterized by a definite
affect of gladness in which there is an air of enjoyment, self confidence and
increased motor activity.
iii. Exaltation:- Intense elation with feelings of grandeur.
iv. Ectasy:- Feelings of extreme joy.
c) Unpleasurable affect:-
i. Depression:- Psychopathological feeling of sadness.
ii. Grief or Mourning:- Sadness appropriate to a real loss.
d) Other affects:-
i. Anxiety:- Feeling of apprehension due to unconscious conflicts.
ii. Fear:- Anxiety due to consciously recognized and realistic danger.
iii. Agitation :- Anxiety associated with severe motor restlessness.
iv. Panic:- Acute attack of anxiety associated with personality disorganization.
v. Free Floating anxiety:- Fear not attached to any idea.
vi. Apathy:- Dulled emotional tone associated with detachment or indifference.
vii. Aggression:- Forceful goal directed action that may be verbal or physical.
viii. Mood Swings:- Oscillation between periods of euphoria and depression.
 ix. Emotional Liability:- It is the rapid change in emotional tone to tears or
laughter with slight or even no provocation.
DISORDERS OF MEMORY
Memory:- Function by which information stored in he brain is later recalled to
consciousness.
Types of Memory:-
 Immediate
 Recent
 Remote
 Immediate:- Ability to recall within 5 minutes e.g. you tell 5 names of unrelated
objects/ things and ask him to repeat within 5 minutes.
 Recent:- Ability to recall events that happened in the last 24 hours. E.g. what he had
to eat at dinner.
 Remote:- Ability to recall the events that happened long time ago childhood memory.
 Amnesia:-Partial or total, continuous, periodic or circumscribed inability to recall
past experiences.
 Paramnesia:- Falsification of memory by distortion of recall.
 Anterograde Amnesia:- Confined to recent events and is progressive.
 Retrograde Amnesia:- Involves the past events and is not progressive.
 Confabulation:- Unconscious filling of gaps in memory by imagined or untrue
experiences.
 Dija Vu:- is an experience of seeing with feeling that one has seen it before but does
not know when or where (is a French term which can literally be translated as already
seen).
 James Vu:- False feeling of unfamiliarity with a real situation one has experienced.
 Hyperamnesia:- Exaggerated degree of retention and recall or excessive retention of
memories specially of details is found in paranoid psychosis and hypomania (is
opposite of amnesia). Patient describes an excessively retentive memory. The events
are described with an extra-ordinary wealth in detail.
 Orientation:- It is ability to recognize the surroundings.
The capacity for orientation involves:-
A. Time
B. Place
C. Person
 Time:- Knowledge of the hour day of the week, date, month, season and year.
 Place:-Name of present location, ones home address, the distance between
present location and home address, reason for being in this place at this time.
 Person:- Identification of self and others in the immediate environment.
 Insight:- Patients assessment of his illness.
 What is the illness?
 Is it physical or mental?
 What are the causes of illness?
  What is the outcome of illness?
 What is the treatment he requires?
 Concentration:- Subtract 7 from 100 and keep on subtracting (until six
successive subtractions are obtained).
If the patient can’t subtract 7 from 100. He can do easier task e.g. 4 times 9 or
5 times 4.
Note:- Examiner does not penalize either for the lack of speed or mistakes he
makes, but then corrects as long as 30 seconds pass between one subtraction
and the next.
 Abstract Thinking:-
 Ask the patient to give similarities e.g. ball and orange.
 Ask the patient to give differences e.g. table and chair.
 Ask the patient to give the meanings of simple.
 Proverbs such as rolling stones gather no moss.
Answers may be concrete giving specific examples to illustrate the meaning or
abstract giving generalized explanation.
 Judgment:- Test judgement- patient’s prediction of what he would be in
imaginary situation. E.g. What he would do if he found a stamped addressed
letter in the street.
 Intelligence:-
 Specific psychological test for I.Q.
 Ask general knowledge questions.
 Ask questions of comprehension and reasoning.
 Mathematical intelligence (addition and subtraction).
 Digit Score test – asking to
Repeat 4-6-3-9-1 and count backwards.
 Performance test.
 Sleep:- Observe patterns of sleep.
 Temporary insomnia
 Persistent insomnia
 Temporary hypersomnia
 Persistent hypersomnia
 Non-organic sleep wake cycle disturbances
 Early morning awakening (E.M.A.)
General observation:- What does the patient do in 24 hours.
Episodic Disturbances:- Like an attack or fit of :-
Epilepsy
Hysterical
Impulsive
Aggressive
Destructive
Observe:-
Frequency
Duration
Precipitating Factor
Description of fit
How is it terminate
What was the behavior after fit.