§ Name: Optional
§ Gender: Male or Female
§ Age: It must be mentioned.
§ Referral: if he is conscious about his mental state or he is
referred by any person or organization
§ Presenting complains: Write in words of patients.
§ Developmental history: How and where person grew up, Any
complications during birth or after birth.
§ Family History: Family Medical and Psychiatric History
§ Medical History: If person is suffering from any physical or
psychological illness
§ Drug History: If person is using any kind of Drug
§ Mental State Examination
Ø Appearance and Behaviour:
Self Care (Reduced with dementia and Depression): How she/he
dressed (culturally adopted or not)
Eye Contact, Face, Pupils dilated and Horizontal creases on
forehead. Etc…
Speech (Rate and Flow + Content)
Ø Cognitive Processes
Memory (short term memory and Long term memory)
Ø Sensorium
General awareness of surrounding
Ø Mood and affect
Elevated or depressed
Delusions
Interaction with others
Ø Intellectual Functions
Perception and Reasoning
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