Specifc points in the psychiatric history

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