Identification

Name, age, occupation, marital status, etc

Refereral: By Who, Why, When

HPC - History of Presenting Complaint

(in patients own words including duration)

How are you? How long have you been here?

Why are you here? Why did you seek help?

Current Symptoms: onset, stressors, duration & course

Sleep: currently, changes over time?

Appetite: normal / increased / decreased?

Memory & concentration changes?

Current Mood:
o

Rate from 1-10.

Classify: Anxious? Depressed? Obsessional? Psychotic?

Screen for relevant events: e.g. recent death of a loved one, back from a war, etc

Details of any help-seeking behaviour.

SR Other Psychiatric Symptoms

Much like doing a Systems Review for organic causes of disease, it is important to go through
a check-list of other Psychiatric Symptoms, noting the positive & negative findings.
For example, a patient with an exacerbation of psychotic symptoms could also have
depression in conjunction, and possibly suicidal ideologies.
It can also be useful to ask your standard Systems Review questions to rule out any organic
causes of the patients presentation.

PHx - Past Psychiatric History

Full details are required of past psychiatric illnesses (e.g. depression, anxiety, etc)
Things to particularly ask about;

Admissions: How many? What for? How long?

Self-harm/Suicide attempts

Treatments: medication, psychotherapy, etc

Adverse reactions or events due to treatments

Support: regular GP/Psychologist

PMHx Past Medical History

Past medical history is useful to ascertain the general health of the patient. In particular,
chronic medical conditions can often cause a decrease in the quality of life for that individual,
which can manifest as psychiatric symptoms. Other points of interest;

Hospitalisations

Surgeries

Allergies, medication sensitivities and current medication (note those with psychiatric
side-effects)

FHx Family History

Many psychiatric disorders have a genetic component and the biological family history is thus
relevant. It can also be useful in guiding treatment and management. It can be useful to draw a
genogram with the patient.
Collecting information from other family members can sometimes allow you to develop a
clearer picture.

Personal History
When taking a personal history it helps to map out the patients life in a longitudinal manner.
Childhood: Birth, development (e.g. motor, verbal & social milestones), family atmosphere?
Happy or Sad childhood?
School: Enjoyed? Got on well with others? Other schooling? Truancy? Academic/sporting
endeavours?
Drug & alcohol use during these years?
Occupation: Level of education completed? Jobs? How long? Why did they leave?
Unemployment?
Psychosexual: Puberty (attitude towards & onset)? Sexual orientation? First experience?
Relationships (past & current)? Marriage? Pregnancies?
It is also important to get a good grasp of the individuals current life situation.

Drug & Alcohol History

Although Drug and Alcohol history can be considered part of Personal History, it requires

special consideration as patients will often avoid discussing this topic. It is important to ask
about alcohol, tobacco and common recreational drugs (e.g. marijuana).
Investigate: first exposure, patterns of use, effects, withdrawal symptoms, impacts on life,
failed treatments or quitting attempts.
A common non-threatening screening tool for assessing alcohol abuse is the CAGE
Questionnaire. It can also be adapted for other drugs.
Two "yes" responses indicate that the respondent should be investigated further. The
questionnaire asks the following questions:

Have you ever felt you needed to Cut down on your drinking?

Have people Annoyed you by criticizing your drinking?

Have you ever felt Guilty about drinking?

Have you ever felt you needed a drink first thing in the morning (Eye-opener) to
steady your nerves or to get rid of a hangover?

Forensic History
Forensic history should be obtained in a non-threatening way (e.g. have you ever been in
trouble with the law?). A history of any misdemeanours and any consequences (e.g. prison)
should be attained.

Premorbid Personality
Premorbid Personality may assist in diagnostic clarification and provides insight into what
strengths/reserves the person may have. A good lead into this is, What sort of person were
you before you developed X?
Other aspects to investigate:

Attitudes to others (social, family, etc) and to self.

Predominant mood

Hobbies & interests

Reactions to stress