Al SAMM ARRAI PSYCHIATRIC INTERVIEW
SHEET
Name : age:
sex:
marital status:
Occupation: address:
date:
Reason and source of referral
i.
PRESENT COMPLAINT AND DURATION:
ii.
HISTORY OF PRESENT ILLNESS:-
This includes: the present problem, duration, causation or precipitating factors (e.g. life events), mode
of onset, severity or symptoms, and progress (e.g. deterioration or fluctuation),
Use simple terms and try to avoid technical scientific terms.
iii.
FAMILY HISTORY:1. Father and mother.
Including: name, age, occupation, health (mental and physical), education, personality, attitude, and
emotional relation of each with the patient. Include divorce and separation from each. If dead include:
time, place, and cause of death and age of the parent and the patient then.
2.
3.
4.
Siblings:
 The rank of the patient.
 In chronological order include: name, age, sex, occupation, marital status, health (mental and
physical), personality, social and economical status, relation with the patient, and his feelings
towards them. .
Relatives:
 Relations and illnesses.
 Ask specifically about abnormal personality, mental disorders, epilepsy, and alcoholism.
Home atmosphere.
iv.
1.
PERSONAL HISTORV:Birth and infancy:
Include: date and place of birth, mother’s condition during pregnancy, delivery (normal, prolonged,
instrumentation, and operations), and health {premature, low-birth-weight. convulsions...etc.).
2.
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3.
Early childhood:
Feeding: breast or bottle.
Development (milestones): teething, talking, walking, bowel and bladder control.
Neurotic symptoms: bed wetting (enuresis), temper tantrum, nail biting, thumb sucking, night
terror, sleep walking, stammering, fears, mannerism, and tics.
Behavior: playing (alone), hostility, hyperactivity, and relations with others especially family
Adolescence and adulthood:
Include: social life (isolation or peer group), difficulties and crises, reaction to maturity, and fantasies.
4.
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5.
Education history:
School: age to start and finish school, name of schools, reaction to school, regularity (school
phobia and truancy with age), difficulties, attitude to teachers and peers, achievements, and
ambitions.
University and higher education.
Occupational history:
Include age of starting to work, list ofjob(s) and duration, changes and causes (if any), regularity, job
satisfaction, economical status, and ambitions.
6.
Menstrual history:
Include: age of menarche and reaction, cycle (regularity, duration, last period), dysmenorrhea,
premenstrual tension, and menopause (time, climacteric symptoms, and reaction).
7. Sexual history:
 Masturbation: worries. guilt, and fantasia,any deviations or dysfunction?
 Orientation: homosexual or heterosexual.
 Experiences: age and type.
8. Marital history;
 Marriage: age. date, and number.
 Partner: name, age. occupation, personality, and health.
 Sex: mode of intercourse, orgasm, frigidity, and impotence.
 Satisfaction and relationship.
 Abortions and contraception.
 Extramarital relationships.
 Children: list in chronological order the name, age, personality, and relation with each.
9. Medical and surgical history:
Include: illnesses, operations and accidents (with time), and treatment of each in order.
10. Past-psychiatric history:
Include: date, duration, symptoms, and treatment of each.
11. Alcohol, drugs and tobacco:
Include: quantity and frequency (evening or all day).
12. Forensic history:
Illegal acts, courts and prison.
13. Present social circumstances:
Include: living standard, interests and hobbies, and financial status.
14. Changing Living places:
Includes moving from rural to urban areas and immigration or others
V. PREMORBID PERSONALITY:
1. Mood: cheerful-despondent flaccid-worried tense-calm optimistic-pessimistic stable-unstable
apathetic-inhibited.
2. Character: decisive-hesitant self-confident-shy-timid tolerant-no restrained- expressive trustingsuspiciousirritable-notsensitive to criticism-not jealous-not
3. Moral: perfectionist, self-critic or self-approving, egocentric (selfish) or altruistic, religious, rigid or
rebellious.
4. Energy: energetic, initiative, sluggish, orfluctuant.
5. Socially: introvert extrovert.
6. Fantasy life: Is he a daydreamer?
7. Habits and hobbies.
Conclude: type of Predisposing Personality type
A-MENTAL STATE EXAMINATION
1. General appearance and behaviour:
 Health: Does he look ill?
 In his age
 Dress: Is it neat? Is it appropriate to weather, sex... etc?
 Cleanliness: combed hair and cut nails.
 Posture: relaxed or stiff.
 Gait: slow, unstable or fast.
 Facialexpression:does he look alert, drowsy, apathetic, happy (smiles, giggles, and laughter),
sad (frowning, angry, or anxious)? Is it unexpressive or inappropriate?
 Behaviour: cooperative, not indifferent withdrawn, welcomes opportunity to express himself.
 Attitude:friendly,frank, open, hostile, bewildered, perplexed, or fearful.
 Activity: retarded (slow, stuporous, or rigid) or overactive (restless, unstable,
shakinghands, irritable, destructive, aggressive).
 Coordination and movement: tics, tremor, stereotype, and mannerism.
 Eye to eye contact.
So he looks
2. Speech:
 Speed: mute, slow fast pressureof speech
 Others: coherent, relevantor not, monotonous, circumstantial, perseveration, word salad, clang association,
punning, nonsense, animal-like sounds, verbigeration, echolalia. Neologism, laconic, or garrulous.
3. Mood:happy-elated-euphoric-exalted, unhappy-sad-depressed, calm, anxious, apprehended, worried
suspicious, restless, irritable, hostile, perplexed, incongruent, unstable, indifferent, or apathy.\
4. A-Thought form disorder:
Slow, fast, flight of ideas, poverty of speech, schizophasia, loss of association between ideas.
B-Thought content:
 Preoccupation.
 Obsession, ruminations and rituals.
 Phobias and apprehension.
 Delusions
5. Disorder of perception:
 Hallucinations: auditory, visual, tactile olfactory, or gustatory. And content (written in his
words)
6. Cognitive function:
 Orientation: time, place, or person Tempo -Spatial.
 Memory: recent and remote.
 Concentration and attention.
 General knowledge.
 Intelligence, mathematics and thinking.
 Judgment.
7. Insight
B-PHYSICAL EXAMINATION
C-PSYCHIATRIC AND PHYSICAL INVESTIGATIONS
D- DIFFERENTIAL DIAGNOSES
Starting from the most to the least probable diagnosis.
F- Management:
A- Immediate
B- Long term
E-Prognosis
Short-term, intermediate and Long-term