Template for history in psychiatry

ID: Name, age, nationality, gender, holding degree, current job if applicable, living with
whom and where, originally from.
Source of referral and reason
Source of information: reliability and if they were good informants.
Chief complain: Areas that the patient of family complains of, and duration.
History of presenting illness:
Patient was in his usual state of health or patient is known case of mental illness,
psychotropic medication he’s on (Generic name not trade) doses and compliance.
Detailed history of chief complains (onset, duration, severity, reason for relapse, precipitating
& relieving factors, impact on the patient).
Functioning: relations, self-care, school, work, daily activities.
Medical interventions if applicable.
Don’t forget SOAP (Suicidality, Organicity, Addiction, Psychosis)
Screening for:
Psychosis: Hallucinations (5 sensory modalities), delusions (thoughts, control, grandiosity,
guilt, persecution/paranoia, perception, reference, nihilistic, somatic)
Mood: Depression, mania
Sleep, appetite
Aggression: physical/verbal
Current substance use
Recent stressors
Suicide/Homicide

Past psychiatry:
First visit, diagnosis
Previous medications, effect/side effects, reason for change
Admissions: reasons, episodes, duration, state of discharge
ECT, follow ups, depot, suicidal history or self-injury.

Past medical/surgical:
Diagnosed with what, previous surgeries and admissions, blood transfusions, head traumas
and motor vehicle accidents.
Seizures, thyroid diseases, metabolic, cardiac, medications.
Family history:
Father/mother: age, current marital status, consanguinity, medical/mental health, their
relationship with the patient.
Siblings: the patient’s order, medical/mental health, their relationship.
Familial history of psychiatry/neurological illnesses. (extended family), history of substance
use, suicide or homicide in the family.

Premorbid personality:
1. Social relations: introvert, extrovert.
2. Activities: hobbies and interests.
3. Prevailing mood: Cheerful, optimistic, pessimistic, stable, fluctuating.
4. Character: hesitant, confidant, shy, timid, tolerant/not, expressive, trusting/suspicious,
irritable, sensitive/not, jealous/not.
5. Attitude towards work and responsibilities.
6. Interpersonal relationships.
7. Standards in morals, religious: selfish, altruistic, rigid.
8. Energy: energetic, initiative, sluggish.
9. Coping.

Personal history:
Type of delivery, term, difficulties prenatal or postnatal, NICU admission, reason.
Developmental milestones: motor, sensory, language, childhood attitude.
School: start, performance, failures, truancy, bullying.
Jobs: current and previous, durations and reasons, promotions.
Psychosexual: Pubertal age, reaction, menstrual regulation, relationships, abuse.
Marital status: duration, numbers, relationships, children.
Criminal history: when, reason, imprisoned or detained, for how long.
Previous substance use: types, amount, frequency, with people or alone, overdoses,
intoxications, mixing.
Details/reason if any stops from school/job
Mental Status Examination:
Appearance and behavior: group age, looks younger/as/older than stated age, body built, eye
contact, comment about clothes, grooming and hygiene, attitude (cooperative, uncooperative,
sarcastic, seductive, aggressive), level of activity, attention, abnormal behavior, hallucinatory
gestures.
Speech: coherent or incoherent, relevant or not, tone volume and rate, articulation.
Mood & affect: type (euthymic, elated, irritable, low, anxious) intensity (restricted, blunted,
flat, exaggerated) stability (labile, sustained) reactivity (reactive/not) appropriate,
congruence.
Thought form: well organized, circumstantial, tangential, flight of ideas, loss of associations,
thought blocking, derailment... etc
Thought content: delusions, over valued ideas, preoccupation, death wishes,
suicidal/homicidal, obsessions.
Perception: hallucinations, illusion, depersonalization, derealization.
Cognition: consciousness, orientation, attention (digit span test, 5 words with the same letter),
concentration (depends on education/possibility: serial 7s test, serial 3, months forward and
backward, days of the week forward and backward), memory: immediate (digit span test),
short term (ask to repeat 3 words the after 5 minutes ask to recall), recent (last few
days/months events), remote (personal or public event), abstract thinking (proverbs or
similarities & differences), knowledge, IQ, visuospatial ability.
Insight: do you believe that: 1. You have abnormal experiences? 2. Your abnormal
experiences are symptoms of an illness? 3. The illness is psychiatric in nature? 4. Psychiatric
treatment might benefit you?
Judgement: what would you do after discharge? Situational: If you smelled smoke in your
house what would you do?

Best of luck,
Dalal AlEesa