Mental Health assessment

1. Psychiatric History Taking
History taking is the process of taking detail
information about patients such as family relationship,
personal bio data, environmental factors, past medical
history, past psychiatric history, etc.

2. Purpose of History Taking
• To collect information about patient’s illness.
• To find out the possible causes of illness.
• To find out the sources of stress.
• To find out the family and social relationship and
support.

3. 1)Patients identification data
Name:–
Age:–
Sex
Address:–
Bed No:–
Education:–
Occupation:–
Marital status:–

4. Religion:–
Income:–
Earning member:-
Date of admissions:–
Language:–
Attending Doctor:–
Diagnosis:-

5. 2. Chief complaints (with duration)
• According to the patient
• According to the informant

6. 3.History of present illness
• When the patient was last well or asymptomatic
• The time of onset
• Duration (weeks/months/years)
• Course of illness (continuous/fluctuating/episodic/
improving/getting worse)
• Precipitating/Predisposing factor
• symptoms in detail in chronological order
• Any treatment prior to admission in the hospital

7. 4. History of past medical, surgical hospitalization
5. Past psychiatric history and history of substance use.
6. Family history
• Type of family
• Number of family member
• Relationship between family members
• Family health history
• history of mental illness in family, suicidal alcohol,
tobacco, drug abuse(write in paragraph)
• Family tree

8. Should be of 3 generation of patient
• Male(no color)
• Female
• Male expired
If shaded full
male psy Patient
Present patient
• Married
• Divorced

9. 7. Personal history
a)Birth and development
– Type of delivery (C/S, normal vaginal
– Place of delivery, date of birth
– Birth weight
– Any problem during postnatal period
– Developmental milestone

10. b)Childhood health and adjustment
– Problem of stuttering, neurosis, nail biting, thumb sucking,
bed wetting, phobia, temper tantrum aggressive
– Emotional problem
c)Educational history
– Age of beginning and finishing education (reason for
termination)
– Relationship with teachers/peers
– Presence of school phobia, non attendance
– Academic achievements

11. d)Menstrual history in female
– Age of menarche
– Cycle of menstruation (regular and monthly)
– Any problem during menses (dysmenorrhea)
– Date of last menstrual period

12. e)Occupational history
– Age of starting job/work
– Type of occupation
– Relational with boss, coworkers, subordinates
– Frequent job changes
– Job satisfaction (any stress/ problems)
– Is the job appropriate to the educational level
– Income

13. f) Social history
– Any involvement in the social activities
– Hobbies and interests
– Habit

14. g) Marital History
– Age at marriage
– Name, age, education and occupation of spouse
– Date and duration of marriage
– Type of marriage: love or arrange
– Number of marriages
– Relation with spouse
– No of children
h)Religious history

15. 8)Pre–morbid personality
– Interpersonal relationship (Extrovert/Introvert)
– Use of leisure time
– Sociable/Helpful
– Presence of religious beliefs and moral attitudes
- fantasies
- Habit

16. • Eating pattern: regular/irregular
• Elimination: regular/irregular
• Use of drug, tobacco, alcohol (if drugs, alcohol and
tobacco then amount, frequencies, duration)