Identifying Data name, sex, age, ethnicity, marital status, religion, occupation, education, living situation, referral source Rel...
Identifying Data
- name, sex, age, ethnicity, marital status, religion, occupation, education, living situation, referral source
Reliability of Patient as a Historian
- may need collateral source for history (e.g. parent, teacher) if patient unable/unwilling to co-operate
Chief Complaint
- in patient’s own words
- duration, previous history of disorder or treatment
History of Present Illness
- reason for seeking help (that day), current symptoms (onset, duration and course), stressors, supports, functional status, relevant associated symptoms (pertinent positives and negatives)
Psychiatric Functional Inquiry
- mood: depressed, manic
- anxiety: worries, obsessions, compulsions, panic attacks, phobias
- psychosis: hallucinations, delusions, thought form disorders
- suicide/homicide: ideation, plan, history of attempts
- organic: EtOH/drug use or withdrawal, illness, dementia
Past Psychiatric History
- all previous psychiatric diagnoses, psychiatric contacts, treatments (pharmacological and non-pharmacological) and hospitalizations
- also include past suicide attempts, substance use/abuse, and legal problems
Past Medical/Surgical History
- all medical, surgical, neurological (e.g. head trauma, seizures), and psychosomatic illnesses
- medications, allergies
Family Psychiatric/Medical History
- family members: ages, occupations, personalities, medical or genetic illnesses and treatments, relationships with parents/siblings
- family psychiatric history: any past or current psychiatric illnesses and hospitalizations, suicide, depression, substance abuse, history of “nervous breakdown/bad nervosa, forensic history, any past treatment by psychiatrist or other therapist
Past Personal History
- prenatal and perinatal history (desired pregnancy or not, maternal and fetal health, domestic violence, maternal substance use, complications of pregnancy/delivery)
- early childhood to age 3 (developmental milestones, activity/attention level, family stability, attachment figures)
- middle childhood to age 11 (school performance, peer relationships, fire-setting, stealing, incontinence)
- late childhood to adolescence (drug/EtOH, legal problems, peer and family relationships)
- adulthood (education, occupations, relationships)
- psychosexual history (paraphilias, gender roles, sexual abuse, sexual dysfunction)
- personality before current illness, recent changes in personality
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