PSYCHIATRIC ASSESSMENT TOOL/ PSYCHIATRIC REPORT

Part 1: PSYCHIATRIC HISTORY

D. Family History
She describes her family as an extended family, she claimed that is living with her grandparents, her sister and her cousin. Her parents are alive and
well however not living with them. Her father is working abroad as a manager in supermarket while her mother is in Manila working as a call center
agent. There are no incidences or histories of mental illness in the family. Home into which the client was born is in the middle class. Parents are
married however they are not in good terms. Client was unplanned but wanted birth.
E. Personal History
1. Prenatal history and mother’s pregnancy and delivery
The client was delivered NSD. No known birth trauma; pregnancy was unplanned but wanted. No birth defects; born with a weight of 6.7 lbs.
Attitude of parents during pregnancy was positive.
2. Birth
October 16, 2007; positive parental reaction towards baby; 2nd child.
Infancy
Breastfed fed for 2 years and was bottle fed complementarily around 6 months-1 yrs old; no feeding problem; no weaning problem; slept at day
and awakens at night (frequently cried); no physical or sexual abuse
3. Early childhood/ Pre-school
The client was more attached to her mother. Her toilet training was early. She usually plays with her elder sister and elder cousin. Favorite play
activity were roleplaying in the classroom setting where she usually is the student along with her sister and their cousin as their teacher.
Personality and temperament as a child is active and cheerful at home but when she is outside, she is shy and timid. Was disciplined by her
grandmother with spanks, whenever she commits mistakes.
a. School
Client started school at the age of 4, she said that she was very shy at first but later on she gets along well with her classmates. She finish
elementary at the age of 12 and finish it with flying colors. Entered high school at the age of 12, she was very shy just like what she had
experienced in elementary but gets along with her classmates. She likes math so much and doesn’t like science because she said that she is
not interested in science because when she speaks of science, the word “blood” comes to her mind and she does not like the thought of
blood. The client said that she is not interested in any sports because she was not a sporty type of person. The client claims that she wants
to be a teacher someday because she likes teaching and helping other people that are having a hard type in their studies. Her relationship
with her classmates and teachers are okay, she claims that she does not have any problem with them.
b. Further personality development
She enjoys playing with her neighbours and her sister and then later on gets scolded by their grandfather because they are going home late.
c. Health status
No illnesses, fell on the stairs and get a minor head stitch when she was 5 years old.
4. Adolescence
▪ Peer relationships
She has around 5-6 close friends, she was more of a follower in their group because she was such a shy girl, she enjoys listening to people.
Idealizes favourite vlogger, Ivana Alawi. She is dramatic at times, she is also sentimental. She can also be antisocial sometimes.
▪ School history and Cognitive and motor development
Adjusted well to school and gets along well with everyone she is with because she is shy however very kind. Relationship with teacher are
okay but claims that she is not a teacher’s pet.
▪ Particular adolescent emotional or physical problems
Her only problem is her being shy which hinders her to express her ideas especially recitations.
Interests and hobbies
Sewing, singing and drawing
Her hobbies includes cleaning and arranging her bedroom, watching vlogs, and editing videos.
▪ Psychosexual history
Acquired sexual knowledge from books, peers and grandparents (wanted them to know the consequences of early pregnancy). Attitude of
parents toward sex is a closed subject however it’s an open subject for grandparents especially her grandmother. Had her first menstruation
at the age of 13, she feels afraid because of her abdominal pain.
Religious background
Free Believers in Christ Fellowship
a. Occupational history
N/A
b. Social activity
Has close friend that she open ups to and get along well.
c. Adult sexuality
N/A
d. Military history
N/A
e. Value systems
Seen as a joy; work is seen as or an opportunity; current is devote and faithful to belief; believes in heaven and hell

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Part 2: MENTAL STATUS EXAMINATION
I. Appearance ___✓_
A. Dress ● Not appropriate socioeducational background
● Appropriate Appropriately dressed for weather with ______
matching colors and patterns. Clothes neat and clean. ❖ Remarks: (Brief nontechnical description)
● Inappropriate ______ Speaks at the level expected of a student,
B. Grooming and Hygiene
● Appropriate Clothes neat and clean. Nails are Affect
properly trimmed ● Appropriate
● Inappropriate ______ to content ___✓_
C. Age appearance: ● Apathetic ______
● Appropriate Appears appropriate to age; not ● Inappropriate ______
looking older or younger than current age ● Shallow ______
● Inappropriate ______ ● Blunted ______
❖ Remarks:(Brief nontechnical description ) ● Flattened ______
_____________________________________________ ❖ Remarks: (Brief nontechnical description)
_____________________________________________ Changes affect from nature of topics discussed
___________________________________________ (becoming more cautious hesitant when talking about
family issues etc.)
II. Behavior
A. Manner of Relating IV. Mood
● Cooperative __✓__ ● Normal ___✓_
● Indifferent ______ ● Anxious ______
● Withdrawn ______ ● Depressed ______
● Defensive ______ ● Happy, elated ______
❖ Remarks: ( Brief nontechnical description) ● Worried ______
Cooperates well with student nurse and answers ● Labile ______
appropriately well with questions ❖ Remarks: (Brief nontechnical description)
B. Psychomotor Is relaxed and at peace when asked
1. Activity
● Appropriate V. Thinking
to situation ___✓_ A. Thought
● Hyperactivity ______ 1. Form
● Retardation ______ ● Normal ___✓_
● Tremor ______ ● Concrete ______
● Purposeless ● Referential ______
Activity ___✓_ ● Illogical ______
● Repetitive ● Scattered ______
Behaviors ______ 2. Progression
2. Posture ● Normal ___✓_
● Normal __✓__ ● Circumstantial ______
● Abnormal ______ ● Tangential ______
3. Gait and station ● Loose
● Normal ___✓__ Associations ______
● Abnormal ______ ● Flight of ideas ______
❖ Remarks: (Brief nontechnical description) ● Blocking ______
_Moves and acts appropriately in terms of interview 3. Content
(gestures congruent with what she is saying) ● Normal ___✓_
C. Speech and language ● Persecutory ______
1. Intensity ● Paranoia ______
● Normal ____✓___ ● Hypochondrial ______
● Loud ______ ● Grandiosity ______
● Soft ____ ● Obsessions ______
2. Pitch ● Phobias ______
● Normal ___✓_ ● Depressive ______
● Monotone ______ ● Poverty
● Wide swings ______ of thought ______
3. Rate ❖ Remarks: (Brief nontechnical description)
● Normal ___✓_ Speaks and answers appropriate to question
● Pressured ______ B. Perception
● Slow ______ ● Normal ___✓_
4. Spontaneity ● Hallucinations
● Normal ___✓_ ▪ Olfactory ______
● Intrusive ______ ▪ Visual ______
● Decreased ______ ▪ Auditory ______
5. Relevance ▪ Tactile ______
● Normal ___✓_ ▪ Visceral ______
● Incoherent ______ ❖ Remarks: (Brief nontechnical description)
● Irrelevant ______ Does not perceive any extraordinary delusions or
6. Deviations illusions during course of interview
● None ___✓_ C. General knowledge
● Aphasia ______ 1. Tests:
● Neologisms ______ a. Last Five Philippine Presidents
● Echolalia ______ ● Benigno Aquino III
● Stammering ______ ● Gloria Macapagal-Arroyo
● Clanging ______ ● Estrada
● Verbigeration ______ ● Fidel Ramos
● Perseveration ______ ● Cory Aquino
7. Vocabulary, diction b. Capitals
● Appropriate to socioeducational background ● Philippines Manila

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 ● Ilocos Norte Laoag 419 914
● Abra Bangued 5372 2735
● China Beijing 19386 68391
c. Three Main Islands of the Philippines 103958 859301
● Luzon c. Visual Immediate 5 mins
● Visayas ● Pencil __✓__ __✓__
● Mindanao ● Chair __✓__ __✓__
d. Date of the Philippine Independence Day ● paper __✓__ __✓__
● June 12 4. Abstraction
e. Title of the Philippine National Anthem a. Sayings
● Lupang Hinirang i. Love yourself before others. How can you give love
f. Name of the Holiday celebrated every November 2 to others when you can’t even love yourself
● All Souls Day ii. Kung walag tiyaga, walang nilaga. You must work
g. Date of Labor Day in the Philippines hard
● May 1 b. Similarities
2. Conclusion i. Axe – Saw both cut
● Normal for socioeducational background ii. Car – Bicycle both roll
__✓__ 5. Calculation and concentration
● Not normal for socioeducational background a. 100 – 7 (serially) 93
______ b. Multiplication
❖ Remarks: (Brief nontechnical description) ● 2x3 = 6
❖ Answers all items correctly ● 4 x 12 = 48
D. Sensorium and Intellectual Function ● 8 x 11 = 88
1. Orientation ● 12 x 5 = 60
Time __✓__ ● 4x3 = 12
a. Place __✓__ ● 24 x 3 = 82
b. Person __✓__ ● 80 x 4 = 160
c. Situation __✓__ c. If bananas cost P20 per dozen, how much do 18
2. Memory bananas cost? P30
a. Remote d. Reverse days of the week: Sunday, Saturday, Friday,
● Normal __✓__ Thursday, Wednesday, Tuesday, Monday
● Impaired ______ e. Reverse months of the year: December, November,
b. Recent October, September, August, July, June, May, April,
● Normal __✓__ March, February, January
● Impaired ______ ❖ Remarks: (Brief nontechnical description)
c. Specific abnormalities Finishes all items correctly
● Amnesia ______ E. Insight
● Hyperamnesia ______ 1. Normal __✓__
● Paramnesia ______ 2. Impaired ______
● Confabulation ❖ Remarks: (Brief nontechnical description) No signs of
3. Retention and Recall disorted insights, insights are congruent with what is
a. Auditory Immediate 5 mins presented
● Purple __✓__ __✓__ F. Judgment
● Steamship __✓__ __✓__ 1. Normal __✓__
● Baguio __✓__ __✓__ 2. Impaired ______
b. Digit span ❖ Remarks: (Brief nontechnical description)
● Forward Span Response ❖ No signs of disorted judgments, judgments are
372 372 congruent with what is presented
4916 4916
82574 82574
396157 396157
● Reversed Response