specifc points in the psychiatric history
Last reviewed 01/2018
This scheme is not a rigid format for taking a psychiatric history. It aims to highlight topics to be covered during the history taking procedure.
- patient details
- name
- age
- status
- occupation
- informant
- name
- relation to patient
- intimacy
- length of acquaintance
- interviewer's impression of informant's reliability
- reason for referral
- a brief statement of why and how the patient came to the attention of the doctor
- presenting complaint
- this may be one item or a list, detailing why the patient has been referred
- history of present illness
- achronological account of the illness from its onset
- family history
- details of parents and siblings
- details of family psychiatric illness or other medical conditions such
as:
- epilepsy
- alcoholism
- drug use
- suicide or attempted suicide
- particular focus on the atmosphere in childhood and any early stresses-including death and separation
- personal history
- the patient's birth & early development, childhood and schooling mentioning significant illnesses and events
- note neurotic symptoms, educational record, occupations
- personality
- the patient's attitudes and beliefs
- moral values and standards
- reactions to stress
- relationships and sexual history
- how the patient acquired sexual information, varieties and frequency of sexual practice and fantasy, marital history with details of engagement, marriage and pregnancies and their outcome
- in females there should be careful enquiry about psychiatric disturbance during and after pregnancy.
- current circumstances
- social
- financial
- relationships
- occupation
- drug history
- past and present
- prescribed and illicit
- alcohol
- smoking
- allergies
- past illness
- past medical and psychiatric history