Scheme history of psychiatry

I. Passport information patient: Surname, first name
Date of birth
Home Address
Job
Profession
Who sent, the date of admission to hospital
Diagnosis on admission:

II. Complaints:

If the patient complains, it is necessary to briefly describe their specific content.

III. Life history (according to patient):

1. Heredity.
2. Preschool: behaviors in the team, favorite games especially education: rigor, despotic parents would apply their sentences; raised alone or in a large family. Relationships with parents, sisters and brothers.
3. The period of study at the school, college, college. Ability, academic performance, interests and hobbies.
4. Work activity, profession. The respective interests of the profession. Attitude. Relationships at work. How often and for what reasons to change jobs.
5. Military service.
6. Sexual development and sexuality. Menstruation, their origin, regularity, being during menstruation. Marriage. Relation to the spouse. Sexual conflicts. Pregnancy, childbirth.
7. Past medical history (in chronological order). You should also find out - how patient tolerates heat, cold, variations in atmospheric pressure.

IV. History of present illness:

To find out what immediately preceded this mental illness, what were the first signs of the disease, when and by whom they are marked and how the dynamics of disease progression. Circumstances and causes of hospitalization. For patients with recurrent income (exacerbation) need to figure out catamnesis - mental health after discharge, the type of outpatient treatment, health status at the time efficiency.

V. Physical examination:

Appearance, his age appropriate. Condition of the skin. Musculoskeletal system. Bodies of circulatory, respiratory, pischevareniya.VI. Neurological research. VII. Mental status: The state of consciousness: the orientation in place and time, of the self. Availability Contact: fully accessible, selectively, not available.
Appearance (neat, sloppy, etc.) and the manner of behavior: the situation adequately, friendly, unfriendly, passive, negative, etc.
Sensation and perception: senestopatii, hallucinations, and other violations of their content.
Attention: sustainable, indirect, Further distracting.
Memory - to describe the violations of memory.
Intelligence: a wealth of knowledge, the ability to recharge them and use them,
Interests of the patient. A critical evaluation of the condition. Installations for the future.
Thinking: the rate of flow of associations (slow, fast). Describe the type of thought disorder: thoroughness, fragmentation, etc. Identified obsessions and delusions, their nature, content. Emotional sphere: mood - adequate situation, lower high. Signs of depression (sadness, anxiety, fear, and the presence of suicidal thoughts), euphoria, dysphoria, emotional stupidity. Motor-volitional: calm, relaxed, excited, motor stalled. Various kinds of excitement and stupor, pathological vlecheniy.VIII. Laboratory and special methods: Blood (general, blood sugar, clotting, RW, HIV, etc.).
Urinalysis.
Fecal (in dysentery group glistonositelstvo etc.).
Radiographic issedovaniya.
ECG
EEG

IX. Diary of Supervision.

X. Diagnosis and its rationale.

XI. Recommended treatment.

Recommendations on discharge.

Forecast.