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    TIPPS Psychiatric Evaluation Proforma

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    knvr2001
    This document contains a psychiatric evaluation proforma with sections for collecting information on a patient's presenting complaints, history, mental status examination, physical examination, assessments, diagnosis, management plan, and prognosis. It collects details on the patient's name, demographic details, symptoms, onset, course, precipitating factors, history of present illness, past psychiatric and medical history, substance use, treatment history, personal history, family history, mental status examination, and physical examination.

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    TIPPS Psychiatric Evaluation Proforma

    Uploaded by

    knvr2001
    355 views7 pages
    This document contains a psychiatric evaluation proforma with sections for collecting information on a patient's presenting complaints, history, mental status examination, physical examination, assessments, diagnosis, management plan, and prognosis. It collects details on the patient's name, demographic details, symptoms, onset, course, precipitating factors, history of present illness, past psychiatric and medical history, substance use, treatment history, personal history, family history, mental status examination, and physical examination.

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    TIPPS-Psychiatric-Evaluation-Proforma

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    This document contains a psychiatric evaluation proforma with sections for collecting information on a patient's presenting complaints, history, mental status examination, physical examination, assessments, diagnosis, management plan, and prognosis. It collects details on the patient's name, demographic details, symptoms, onset, course, precipitating factors, history of present illness, past psychiatric and medical history, substance use, treatment history, personal history, family history, mental status examination, and physical examination.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    355 views7 pages

    TIPPS Psychiatric Evaluation Proforma

    Uploaded by

    knvr2001
    This document contains a psychiatric evaluation proforma with sections for collecting information on a patient's presenting complaints, history, mental status examination, physical examination, assessments, diagnosis, management plan, and prognosis. It collects details on the patient's name, demographic details, symptoms, onset, course, precipitating factors, history of present illness, past psychiatric and medical history, substance use, treatment history, personal history, family history, mental status examination, and physical examination.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 7

    PSYCHIATRIC EVALUATION PROFORMA

    Name: ____________________________________ Hospital No. __________________


    Age: ____ yrs Sex: M/F Occupation: _____________ Rural/urban
    Education: Illiterate/primary/high/graduate/professional Referred by: Self/GP/MHP/others
    Economic status: LSES/MSES/HSES Marital status: Single/married/widowed/separated
    Contact (address, Ph No.)__________________________________________________
    Informants:Name _____________________________Relationship ______________________
    Reliability: yes/no Adequate: yes/no
    Presenting complaints:
    1.
    2.
    3.
    4.
    Duration: _________ Age at onset:_____(month/year)________Onset: Abrupt/Acute/Insidious
    Course: Episodic/Continuous/Fluctuating Precipitating factors: yes/no (specify)

    HOPI: (Briefly mention important points in history)

    TIPPS – Training Initiative for Psychiatry Postgraduates


    TIPPS – Training Initiative for Psychiatry Postgraduates
    Negative history: manic/depressive/FRS/other psychotic/anxiety/others (mention briefly)

    Biological functions: Sleep: normal/impaired Appetite: normal/impaired


    Socio-Occupational functioning: normal/impaired
    Substance use: (alcohol/nicotine/cannabis/opioids/others) - dependence / abuse / lifestyle use

    Duration of use:
    Last use of substance:
    Organicity: Yes/No (specify)

    Harm to self: yes/no (if yes) Intentionality: Lethality:


    Legal issues: Yes/No (specify) Harm to others: yes/no

    Treatment history:
    Drug naïve - Yes/No Alternative medicine – Yes/No Compliance: Good/poor
    Drug Dose Duration Efficacy Side-effects

    Past history: medical/psychiatric/nil

    Family history:
    Psychosis/mood disorder/suicide/substance/others/medical/nil (specify) 1˚ /2˚ /3˚ relative

    Living arrangement: Nuclear/joint Caregiver: parent/spouse/sibling/others


    Interpersonal issues: yes/no Expressed emotions: yes / no
    Family understanding of illness: adequate/partial/nil
    3 generation genogram

    TIPPS – Training Initiative for Psychiatry Postgraduates


    Personal history:
    Birth & development: FTND/LSCS/forceps/premature (LBW)/postdated
    Milestones: normal/delayed Childhood: ADHD/ODD/CD/behavioral problems/nil

    School: Education upto: Performance: good/average/poor


    Occupational: Nature of job: Longest duration:
    Marital/Sexual Age of menarche: Menopause:
    Substance Use: LMP: Regularity of cycles:
    PMD:
    Premorbid personality:
    Well adjusted/schizoid/paranoid/dissocial/histrionic/EUP/AAP/anankastic/dependent/others (specify)

    Temperamental history (where applicable):


    Easy / slow to warm / difficult child

    Mental status examination:


    General appearance and behavior:
    Dressing and appearance: Rapport:
    Eye to eye contact: Tics/mannerisms/catatonic signs/others
    Psychomotor activity: normal/increased/retardation/agitation
    Speech: Spontaneous: yes/no Tone/Tempo/Volume: inc/dec/normal Prosody:
    Reaction time: inc/dec Relevant/irrelevant Coherent/incoherent
    Thought: Formal thought disorder: present / absent
    Stream: Flight of ideas/circumstantiality/retardation/though block/perseveration
    Possession: obsessions/compulsions/though alienation (specify)

    Content: Delusions (type):

    Single/multiple elaborate/non-elaborate bizarre/non-bizarre systematized/non-systematized


    Overvalued ideas/depressive cognitions/death wishes/suicidal ideation/anxious or somatic
    preoccupation/others/normal

    TIPPS – Training Initiative for Psychiatry Postgraduates


    Mood: Subjective:
    Objective: euthymic/depressed/euphoric/irritable/anxious/restricted/blunt Range: normal/restricted
    Reactivity: present/absent Appropriate: yes/no Congruent: yes/no Lability: yes/no

    Perception: normal/auditory/visual/olfactory/gustatory/tactile (mention briefly)

    Other psychopathology: Depersonalization/Derealization/Somatic passivity

    Cognitive functions:
    Consciousness: alert/drowsy/obtunded/stuporous Orientation: Time/Place/Person
    Attention: sustained/ill sustained/impaired

    Language: normal/fluency impaired/comprehension impaired/global impairment/neologism/paraphasia

    Memory: Registration Recall: Normal/Recall with cues/impaired/confabulation


    Remote memory: normal/impaired

    General information: Normal/inadequate Calculation: Normal/impaired

    Abstraction: Differences: abstract/semi-abstract/concrete Similarities: abstract/semi-abstract/concrete


    Proverb: abstract/semi-abstract/concrete

    Judgement: Test: intact/impaired Personal: intact/impaired Social: intact/impaired

    Insight: Awareness: yes/no Attribution: Acceptance: yes/no

    Grade of insight:

    Lobe function tests:

    TIPPS – Training Initiative for Psychiatry Postgraduates


    Physical Examination:

    Pulse: BP: RR: Weight: Height: BMI:

    General Physical Examination: pallor/icterus/cyanosis/clubbing/lymphadenopathy/edema

    External injuries:

    Thyroid:

    CVS:

    RS:

    P/A:

    CNS:

    Higher Mental Functions:

    Cranial Nerves:

    Motor system: Tone: Power: UL: LL:

    Reflexes: UL: LL: Superficial reflexes: Gait

    Sensory system: Fine touch: Crude touch: Pain:

    Joint position and vibration sense:

    Cerebellar signs:

    Primitive reflexes:

    Assessed by: (name & designation)

    TIPPS – Training Initiative for Psychiatry Postgraduates


    Formulation:

    Diagnosis:

    Management Plan:

    Assessments & Investigations:

    Pharmacological

    Non Pharmacological:

    Prognostication:

    Next follow up date:

    TIPPS – Training Initiative for Psychiatry Postgraduates

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