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a. Name:
b. Age:
c. Marital states:
d. Education:
e. Address:
f. Sex:
g. Occupation:
h. Informant:
I.
II.
III.
IV.
Name:
Age:
Relation with the patient:
And acquaintance:
Presenting Complains:
Past History:
a) Past Psychiatric History:
Family History:
Father:
Alive or dead:
Age:
Level of personal health:
Occupation:
Relationship with the patient:
Mother:
Alive or dead:
Age:
Level of personal health:
Occupation:
Relationship with the patient:
Sibs:
Alive or dead:
Age:
Level of personal health:
Occupation:
Personal History:
a) Gestational period:
b) Birth History:
e) Adolescence:
Systemic examination:
Detail examination of GIT,
CVS,
CNS,
Respiratory system,
and Genitourinary system.
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b) Facial Appearance.
d) Social Behavior.
Speech:
Quantity:
Quality:
Flow of speech:
Mood:
Delusions:
Hallucinations:
Cognitive Processes:
a)
Orientation.
Time:
Place:
Person:
b)
Concentration.
c)
Memory.
Immediate:
Short term:
Long term:
d)
Abstract thinking.
Reasoning:
Judgment:
Proverb:
e)
Insight.
Nominal Dysphasia:
Co-ordination:
Comprehension:
Reception:
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Management Plan:
Immediate:
Inpatient / outpatient.
Short term:
Investigations:
Labs:
Psychological:
Interview family to gather information:
Interview Nursing staff to gather information:
Interview friends/relatives/teachers to gather
information:
Self observation:
Psychometry:
Radiological:
Differential Diagnosis:
1.
2.
3.
4.
Tentative diagnosis:
3.
Treatment Plan:
Treatment on Discharge:
Follow up:
Prognosis:
Short term Prognosis:
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