Psychiatry History Taking Format
Psychiatry History Taking Format
Psychiatry History Taking Format
IDENTIFICATION
• Name:
• Age:
• Sex:
• Marital Status:
• Educational Status
• Occupation:
• Religion:
• Caste:
• Residence:
Present address:
Permanent address:
• Source of referral:
• Informant (name, age, relationship, intimacy and length of acquaintance with the
patient)
Reliability of information:
Adequacy of information:
PRESENTING COMPLAINTS: (with duration)
Patients:
Informants:
HISTORY OF PRESENT ILLNESS:
• Duration
• Onset
• Course of illness : continuous or episodic or continuous with exacerbations
• Progression of severity
• Precipitating factor
• Description of presenting complaints in detail.
• Relevant positive and negative points.
• Biological symptoms : comparison past and present :sleep, appetite, loss of weight,
libido
• Personal care, work performance, personality changes.
• Treatment history and its effect on course and severity of illness.
PAST HISTORY
• Psychiatric
• Relevant Medical
• Relevant Surgical
FAMILY HISTORY
Family of origin
Describe with a family chart.
Presence or absence of –
• mental illness, t/t
• alcohol or drug abuse
• suicide, unnatural death, disappearance
• medical problems like DM, Thyroid dysfunctions, Neurodevelopmental problems
Relationship, communication pattern among them
Attitudes, beliefs regarding illness, choice of treatment
Personality characteristics, Subsyndromal symptoms
PERSONAL HISTORY
• Antenatal, natal
• Events after birth: crying, breathing, cyanosis, icterus, high temperature, convulsions, or
any other abnormalities.
• Milestones: motor, language, social, emotional psychosexual
• Childhood temperaments
• Presence of neurotic symptoms: e.g. thumb sucking, bed wetting, temper tantrums etc.
• Academic history
• Sexual history
• Menstrual history
• Work history
• Patient’s family. Marriage, children, relationship, dynamics, presence of mental illness
or alcohol or drug abuse.
PREMORBID PERSONALITY
Characteristics possessed by a person that uniquely influences his or her cognitions, emotions,
motivations and behaviors in various situations.
Hobbies and leisure activities
Relationships- family, friends, work
Mood-cheerful/gloomy; shows /hides emotions
Character-Negative: shy, rigid ,sensitive, suspicious, self-centered, quarrelsome
/Positive: confident, punctual
Attitude/Standards/Morality –body, health, religion, politics
Orientation:
Knowing state of oneself and surrounding in terms of time, place, person
a) Time: Time; period of day; day; date; week; month; year.
b) Place: Ward, hospital; home; area; city, town, village, district; zone, region, country,
continent.
c) Person: Doctor, informant, visitor, nurses and others.
Intelligence:
Ability to understand, recall, mobilize and constructively integrate previous learning in
meeting new situation
Average or below average. (Assess from education level, work performance, ability to
tackle novel situations on his/her own e.g. a young girl handling and unexpected guest
at home in absence of other family members etc.)
Judgment:
Ability to assess a situation correctly and to act appropriately in the situation
a) Social: Behavior during interview and other social settings.
b) Test: well stamped envelope test; or house on fire test or facing a snake
suddenly test.
Grasp of general knowledge: Names of well-known people e.g. prime minister; places; capitals;
tools etc.
Insight: Patient’s degree of awareness and understanding about being ill.
Do you think you have a problem?
What kind of problem do u think?
Do you need treatment?
Do you think treatment would do good?
What are your future plans?
Present/Partial/Absent