Copy Of Mse

1 CASE HISTORY INTAKE FORM NAME:

SEX:

AGE:

DATE OF BIRTH:

EDUCATION:

OCCUPATION:

INFORMANT:

RELATIONSHIP:

1. PRESENTING COMPLAINT:

2. HISTORY OF PRESENTING ILLNESS

3. PAST HISTORY

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4. FAMILY HISTORY OF MENTAL ILLNESS POSITIVE HISTORY OF PSYCHIATRIC ILLNESS IN THE FAMILY:

FAMILY TREE

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5. SOCIAL RELATIONSHIPS With Parents: With Siblings: With Peers: At Work: Any Others: 6. PERSONAL HISTORY Birth and Childhood History Home Delivery □ □ □ Hospital Delivery Normal Caesarian Specify if any other Birth Cry Yes No Milestone Development History

No complications Complications Specify if any

Reference

3 □ Crawling □ Talking □ Walking 7. EDUCATIONAL HISTORY Level of Education: Education □ Continuous □ Disrupted Stage: Reason: □ Educational Achievements

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8. OCCUPATIONAL HISTORY Field of Work: Monthly Income: Work Pattern Before illness: Coping Strategy for Work Related Stress:

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9. MARITAL HISTORY Period of Marriage: Number of children: Age: Class: Spouse Detail: Name: Education: Relationship with Spouse: Children: Marital Problems {if any}

10. MENSTRUAL HISTORY {for female}  

Age of Puberty: Menstrual cycle □ Regular □ Irregular Treatment taken Any Related Problems:

11. PREMORBID PERSONALITY

12 Months 12 Months 18 Months

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Social Interaction Pattern □ Extrovert □ Introvert □ Ambivert □ Neurotic

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Leisure Time Activity: Religious Belief: Fantasy Life:

MENTAL STATE EXAMINATION 1. APPEARANCE AND BEHAVIOR: ♦

Initial Appearance Consciousness □ Conscious □ Semiconscious □ Unconscious

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Weight

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□ Obese □ Over-weight □ Under-weight □ Emaciated Hair □ Well groomed □ Unnatural □ Uncared

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Grooming □ Disheveled □ Soiled □ Body odor □ Halitosis Dress □ Undressed □ Underdressed □ Overdressed □ Bizarre  Other Features □ Wounds □ Scars □ Jewelry

5 Glasses Dental braces Behavior Walk □ Gait/march □ Limp □ Shuffle □ Assisted

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Repetition □ Gestures □ Twitches □ Stereotypical □ Automatism □ Mimicry □ Echopraxia Overactivity □ Psychomotor Agitation □ Hyperactivity □ Tic □ Sleepwalking □ Compulsion Eye Contact □ Normal □ Hesitant Eye Contact □ Gaze Aversion □ Staring Vacantly □ Staring at the Examiner

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SPEECH Speech Rate □ Rapid □ Slow Intelligibility Slurred Mumbled Stutters Accented Volume □ Loud □ Whispered □ Audible Tone High Pitch Normal Pitch Low Pitch Speech Quality

6 □ Hesitant

□ Emotional □ Monotonous □ Stereotypical □ Unspontaneous □ Echolalia □ Verbigerative Speech Quantity {Speech Productivity} □ Garrulous □ Talkative □ Responsive □ Taciturn □ Mutism Reaction Time □ Low □ Fast

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Attitude to Examiner Seductive Playful Ingratiating Friendly Cooperative Interested Attentive Frank Indifferent Evasive Defensive Hostile

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3. MOOD & AFFECT Mood Subjective □ Ecstatic □ Euphoric □ Expansive □ Elevated □ Euthymic □ Dysphoric □ Anhedonic □ Depressed □ Alexithymic □ Grieving Other Emotions □ Panicked □ Fearful □ Anxious

Objective

7 Tense Agitated Apathetic Irritable Angry Other Signs □ Ambivalence □ Mood Swings

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Neuro-Vegetative □ Anorexia □ Insomnia □ Hypersomnia □ Constipation 4. THOUGHT PROCESS Thought Content □ Poverty of thought □ Overvalued idea □ Egomania □ Monomania □ Hypochondria □ Obsession □ Compulsion Delusions Bizarre Systematized Mood-congruent Mood-incongruent Nihilistic Somatic Paranoid Persecutory Grandeur Referential Self-accusatory Control Thought withdrawal Thought insertion Thought broadcasting Infidelity Phobia Yes No If yes Specify: Preoccupations/ Suicidal Ideation Ideation history

Subjective

Objective

8 Previous attempt/s Current ideation Impulsiveness Viable plan 5. PERCEPTION Hallucinations Time Hypnagogic Hypnopompic  Type □ Auditory □ Visual □ Olfactory □ Gustatory □ Tactile □ Somatic □ Hallucinosis 6. ORIENTATION □ Time Disorientation □ � Place Disorientation □ � Person Disorientation 7. ATTENTION & CONCENTRATION

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Attention □ Attentive □ Selective attention □ Distractible □ Inattentive ♦ 

Concentration Digit Forward Test □ Normal □ Ok □ Impaired  Digit Backward Test □ Normal □ Ok □ Impaired

8. MEMORY □ Remote memory deficit □ Recent past deficit □ Recent memory deficit □ Immediate recall deficit 9. ABSTRACT THINKING □ Simple Calculation □ General Fund of Knowledge □ Proverb Testing: 10. JUDGEMENT □ Test Judgement

9 □ Social Judgement □ Personal Judgement 11. INSIGHT □ True Insight □ Impaired Insight REMARKS

GLOSSARY

1. Alexithymic. Relatively undifferentiated emotions (unableto identify or express emotion), and thinking tends to dwell excessively on the mundane. Detached, and may seem to dissociate. 2. Anhedonic. An inability to enjoy anything, even things once enjoyed. 3. Automatism. Automatism refers to activity performed without conscious awareness and usually followed by complete amnesia 4. Dysphoric. Feeling unwell or unhappy. 5. Echopraxia. Involuntarily imitation the movements of another. Echopraxia is also known as echomotism. 6. Garrulous. Given to excessive and often trivial or rambling talk; tiresomely talkative 7. Halitosis. Bad breath 8. Hallucinosis. A mental state in which the person has continual hallucinations. 9. Hypnagogic Hallucination. Threatening hallucinations at the moment of falling asleep. 10. Hypnopompic Hallucination. Threatening hallucinations at the moment of waking from sleep. 11. Hypochondria. Abnormal anxiety about one's health; the 12. persistent neurotic conviction that one is or is likely to 13. become ill. 14. Monomania. Preoccupation with a single object 15. Mutism. Unable or unwilling to speak. 16. Somatic Hallucination. Hallucination involving the sensation of being strangled, feeling that insects are crawling beneath the skin, or feelings of sexual stimulation. 17. Taciturn. Habitually untalkative. 18. Tic. Part of the body moves repeatedly, quickly, suddenly and

uncontrollably.

19. Verbigerative. Involuntarily repeating of certain words and/or phrases.