FORMAT FOR MENTAL STATUS EXAMINATION: HISTORY TAKING:

Date.. Students name.. Biodata of the patient: Name: Age: Sex: Marital status: Educational status: Occupation: Religion: Caste: Residence: Present address(with duration of stay): Permanent address: Source of referral: Informant (name,age,relationship,intimacy and length of acquaintance with the patient) Reliability of information: Adequacy of information: PRESENTING COMPLAINTS :( with duration) Patients: Informants: HISTORY OF PRESENT ILLNESS: Onset ,duration and mode of onset: Precipitating factor: Course of illness continuous or episode or with exacerbations

Progression of severity: (Describe the present episode of abnormality in detail.Describe the presenting complaints in detail. Relevant positive and negative points.Biological symptoms and consequences of illness sleep,appetite,loss of weight,libido,personal care ,work performance,personality changes.) Treatment history and its effect on course and severity of illness. PAST HISTORY: Psychiatric: Medical:

FAMILY HISTORY: Patients family or origin.Describe with a family chart.Presence or absence of mental illness,alcohol or drug abuse among close relatives.Relationship among them,quality of relationship,family dynamics.(family history,current social situation,family structure) PERSONAL HISTORY: Birth Events during pregnancy Birth weight Events after birth:(crying,breathing,cyanosis,uterus,high temperature,convulsions,or any other abnormalities). Milestones:motor,psychosocial Presence of neurotic symptoms e.g.thumb sucking,bed wetting,temper tantrums etc. Sexual history Menstrual history:age of menarche,did u have menstruation regular,was any problem during menses?

Work history: When he started the job,status of patient in working place,attitude towards work and job satisfaction,frequency of changing job. PREMORBID PERSONALITY: Interpersonal relationship(extrovert/introvert),attitude toward work,family,predominant(optimistic/pessimistic/stable/fluctuating/cheerful), use of leisure time,religious beliefs and moral attitudes.relationship towards family and friends,description of the patient before onset of illness.information drawn for informant than the patient.

EXAMINATION OF PATIENT: Physical Examination General Systemic(All systems including neurological examination) MENTAL STATE EXAMINATION( for cooperative patient) 1.GENERAL APPERANCE AND BEHAVIOUR: Level of consciousness Body build,facial expression,hygiene,dressing Posture-relaxed,strange/odd posture,waxy flexibility. Level of activity-under activity/over activity Type of movement-appropriate,awkward,purposeful,aimless,self injuries,destructive,mannerisms,tics,grimaces,echopraxia Level of communication,psychomotor activity Attitude towards examiner:cooperative,attentive,interested,frank,hostile. Eye contact:Normal eye contact/hesitant eye contact/staring at the examiner.

2.TALK OR SPEECH: Spontaneous or non spontaneous Intensity:Audible/Excessively loud/Abnormally soft Reaction time:Normal/very slow/rapid Speed:Normal/very slow/very rapid Deviation:Rhyming/echolalia/Neologism/Verbegiration,stuttering circumstantiality,tangentiality,stereotype,clang association,flight of ideas. 3.MOOD AND AFFECT: Subjective:patients own assessment Objective:(examiners assessment) -Facial expressions-Anxious,depressed,elated,dull,angry,irritable -observe for appropriateness,anhedonia and other mood disturbance. 4.THOUGHT: a.Form and stream of thought: -loosening of association -Flight of ideas -circumstantiality -Tangentiality -Thought blocking -perseveration b.progression of thought: c.content of thought: -obsessive ideas -Phobias -Depressive ideas -Delusion: Persecutory delusion,Grandiose delusion,Hypochondrical delusion,guilt,Nihilistic delusion,Delusion of reference,Delusion of control

-Peculiar ideas about interpersonal relationships 5.PERCEPTION: Hallucination,illusion,or other perceptual abnormalities 6.ATTENTION AND CONCENTRATION: (Ask him 100 minus 7 test,names of days or months in reverse order,note mistakes committed,time taken;preservation,etc.) 7.MEMORY: a.Immediate: use digit forward and digit backward test,ask to repeat pair of words or a story at least after 5 minutes. b.Recent: From 24 hours within the past 2 weeks c.Remote: Ask for date and place of marriage,name and birthdays of children 8.ORIENTATION: a.Time:time,period of day,date,week,month,year b.Place:Ward,hospital,home,area,city,town,village,district,zone,religion,country,contine nc.Person:Doctor,informant,visitor,nurses and others. 9.INTELLIGENCE: Based on his educational background -simple arithematic calculation -general knowledge -Reading,writing etc 10.JUDGEMENT: a.Social:behaviour during interview and other social settings.

b.Test:Assess with standard tests like well stamped envelop test,or house on fire test or facing a snake suddenly test.Type of response,its appropriateness,time taken etc 11.INSIGHT: Present ,partially present or absent 12.ABSTRACT THINKING: (Assess:patients concept formation) e.g.proverb testing:the meaning of simple proverb should be asked similarities and difference between familiar objects should be asked SUMMARY: SPECIAL POINTS: 1.Sleep pattern:Insomnia,Hypersomnia,EMA(Early morning awakening),Late sleeping 2.Appetite 3.Bowel and bladder habits BASELINE DATA: Height,Weight,Vital signs LABORATORY DATA TREATMENT Date Name of the drugs Dosage and frequency Nurses responsibilties