Child & Adolescent Psychiatry History Outline V2

1. Identifying Data 6. Family history

a. Name, Age a. History of Psychiatric Problems
b. Living Situation b. History of medical problems
c. Strengths & Interests 7. Developmental History
d. Supports a. Pregnancy
2. Reason for Referral/Chief Concern (s) b. Birth
a. Referring Physician’s RFR c. Temperament
b. Family’s Chief Concern(s) d. Milestones
c. Patient’s Chief Concern e. School History
3. History of Presenting Illness i. Preschool
a. Symptoms ii. Elementary School
b. Stressors iii. High school
c. Timing iv. Current
i. Onset 1. Grade & Teacher(s)
ii. Peak of problems 2. School Problems
iii. Problems at their least 3. School Supports
iv. Current problem status 8. Social History
v. Overall Progression a. Family background
d. Therapy b. Family strengths & stressors
i. What has been tried and c. Trauma/Abuse History (can go in
how effective (ineffective) above Psychiatric ROS)
have the therapies been d. Substance History (can go in above
e. “FIFE” Psychiatric ROS)
i. Feelings of the 9. Mental Status Exam
patient/family about the 10. Impression
problem a. ID
ii. Ideas of etiology b. Presenting symptom cluster and
iii. Function (level of level of impairment
impairment) c. Provisional diagnosis and rationale
iv. Expectations d. Bio-Psychosocial Formulation (The
f. Psychiatric ROS Why of the problem)
4. Psychiatric History i. Predisposing factors
5. Medical History ii. Precipitating factors
a. Allergies iii. Perpetuating factors
b. Current Medications iv. Protective factors
c. Medical ROS (neuroveg sx) e. Prognosis (how to improve)
d. Past Medical Problems 11. Provisional Diagnosis(es) and Differential
12. Recommendations/Plan (Next steps)
a. Safety
b. Bio
c. Psychosocial

Last Updated by Kelly Saran, MD October 2016