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Psychiatric Assessment >> History

imageIdentifying 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


Psychiatric Assessment >> History

Psychiatric Assessment >> Mental Status Exam (MSE)

Psychiatric Assessment >> Mental Status Exam (MSE) (continued 2)
Psychiatric Assessment >> Mental Status Exam (MSE) (continued 3)
Psychiatric Assessment >> History Psychiatric Assessment >> History Reviewed by Radiology Madeeasy on April 09, 2011 Rating: 5
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