COLLEGE OF NURSING

- : - Psychiatric Nursing History - : -

Name of the student :Year :

I. IDENTIFYING DATA: -

Name of the Patient: ……………………………………………………………

Age: ……………………………………………………………………………

Sex: …………………………………………………………………………….

Ward No.: ………………………… Hospital Regd. No.: ……………………

Education: …………………………………………………………………….

Occupation: …………………………………………………………………….

Income: ………………………………………………………………………...

Marital Status: ………………………………………………………………….

Religion: ………………………………………………………………………..

Address: ………………………………………………………………………..

Date of Admission: ……………………………………………………………

Duration of Nursing: …………………………………………………………...

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Final Diagnosis: ………………………………………………………………..

II. a) INFORMATE

b) RELIABILITY OF INFORMANT

III. PRESENTING COMPLAINTS OR PROBLEMS: -

According to the patient:

According to the Relative:

IV. HISTORY OF PRESENTING COMPLAINTS: -

V. PAST HISTORY OF ILLNESS: -

- Medical Illness

- Psychiatric Illness

VI. PERSONAL HISTORY: -

- Infancy

- Childhood

- Adulthood

- Late Maturity

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VII. FAMILY HISTORY

VIII. PREMORBID PERSONALITY

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