Name: Address:

Marital status: No. of children:

Occupation: Ethnicity:
GP: Date of birth:

SOURCE OF REFERRAL:

EXPECTATIONS:

MAIN COMPLAINTS:

HISTORY OF PRESENT ILLNESS:

(Onset – insidious/acute; precipitating events; perpetuating events)

FAMILY HISTORY

Parents: (age, whereabouts, physical/mental health, occupation, and relationship with

client. If dead: age at time of death, client’s age at time of death, cause of
death.)

Father:

Mother:

Siblings: (names, ages, and significant information)

PERSONAL HISTORY

Place of birth:

Who brought client up: (pregnancy, birth complications)

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Pre-school: ( family atmosphere, exposure to violence, milestones, difficulties including
conduct disorder)

School: (to include primary and secondary schooling, academic achievements, peer
relations, teacher relations, truancy, specific learning disabilities, conduct
disorder)

Other notable childhood events: (e.g. history of sexual or physical abuse, cruelty to
animals, arson)

Higher education / training / apprenticeships:

Occupations: (list chronologically, satisfaction, competence, reasons for change etc)

Sexuality: (previous partners, reasons for separation, age at 1 st boy/girlfriend,

puberty/menarche + 1st sexual experience, problems, fantasies, hetero/homo, abnormal
sexual preferences/behaviour)

Current partner: (e.g. name, length of relationship, age, occupation, partner’s health,
positives/negatives)

Children: (List pregnancies chronologically, names and ages of children,

comments, terminations, miscarriages)

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Current drug and alcohol use (date: )

Yes / No Yes / No
Alcohol Solvents
Marijuana Opiates
Benzodiazepines Cocaine
Amphetamine-like Hallucinogens
Anticholinergics Others

Details for each significant substance:

(e.g. average amount used daily or weekly, adverse consequences – social / work / legal /
health, history of symptoms of tolerance or withdrawal)

Past drug and alcohol misuse:

Medical history: (List surgical operations, serious medical illness, time spent in
hospital, contraception, and disabilities)

Investigations:

PAST PSYCHIATRIC HISTORY

(To include dates of all admissions (1st, 2nd, 3rd etc), MHA status, circumstances, mental state
and progress for each admission, diagnostic formulation, mental state on discharge,
discharge plan and medication on discharge. For community care include community team,
accommodation, occupation, medication {and compliance})

DOCUMENTATION OF RISK TO OTHERS (date: )

Past history of violent behaviour:

(Dated and chronologically listed vignettes of violent actions to include circumstances, type of
victim, mental state at the time, whether receiving treatment, misuse of substances, attitude
to the event.)

Previous imprisonment / appearances before the Court:

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Attitudes relevant to risk: (e.g. remorse for past actions, paedophilia, impulsivity etc)

Mental state characteristics (when unwell) relevant to risk:

(e.g. morbid jealousy, delusions of persecution, delusions of being controlled, command
hallucinations, and heightened affect associated with the above.)

Formulation of risk to others (to be duplicated on red hazard sheet):

DOCUMENTATION OF RISK TO SELF (date: )

Past history of self harm:

(Dated and chronologically listed episodes of self-harm, including degree of planning, context,
means used, whether in the presence of others, mental state and use of substances at the
time, seriousness of the attempt.)

Attitudes relevant to risk: (e.g. attitudes to religion and death)

Presence of factors statistically associated with attempted suicide:

(e.g. alcohol and/or drug dependence, physical illness, loneliness, epilepsy, hopelessness,
schizophrenia)

Mental state characteristics (when unwell) relevant to risk):

(e.g. depression, hopelessness, psychosis involving commands to self-harm, impulsive or
aggressive tendencies)

Formulation of risk to self (to be duplicated on red hazard sheet)

SOCIAL SITUATION:

Accommodation: (Type; quality; personal space; identity of other residents; ease of

access; physical security; domestic violence*; nature and quality of
neighbourhood)

Finances: (Sources of income; capital; expenditure – including special liabilities

such as gambling; debts – including threats of punitive action such
as withdrawal of services or eviction; budgeting capacity)

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Home activities: (e.g. way of spending a typical day – includes waking and rising,
daily routines; daily living skills – including personal hygiene, laundry,
cooking, cleaning; recreational activities; visitors; relationships with
immediate neighbours)

Outside activities: (e.g. occupation; social contacts - family, friends, others; shopping;
travel; use of public amenities – e.g. hotels, cinema; other outside
leisure activities; religious observance; holidays)

Carers:
♦ informal carers:
(Facts; problems; services; strengths)

♦ professional carers:
(Facts; problems; services; strengths)

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PERSONALITY:

Important personality traits / religious and spiritual beliefs:

(e.g. self-esteem, coping with anger and stress, dependence, sociability, compulsiveness,
stability of relationships)

Premorbid:
(e.g. How does s/he get on with people? – paranoid; does s/he have many friends? -
schizoid; does s/he trust other people? (impulsive, paranoid)*; what is his/her temper like? –
antisocial*; how does s/he cope with life? – anxious, borderline; is s/he anxious or shy? –
avoidant; how much does s/he depend on others – dependent; how much does s/he
respond to criticism? – anxious, paranoid; is s/he overemotional or irresponsible? –
histrionic, antisocial, borderline*; does she have unusually high standards at home or at
work? – anankastic)

Current:

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MENTAL STATE EXAMINATION:

Appearance & General Behaviour:

(Cleanliness, self-care, hair, cosmetics, dress, behaviour towards others, * relaxed x tense
and restless, slow, hesitant, repetitive, purposeful x meaningless movements, arousal,
frightened, perplexed, etc)

Talk (form):
(Little, much, spontaneously, slowly/quickly, hesitantly/promptly, to the point/wide of it,
coherently, anxiously, discursively, loosely, etc – GIVE VERBATIM SAMPLE)

Mood:
(Diurnal variation, libido, also include anxiety, fear, suspicion, anger, etc)

Affect (physical expression of emotion):

(Range, congruity, lability, etc)

Thought Content:
(Morbid thoughts and preoccupations, phobias, obsessional ruminations, compulsions,
rituals)

Abnormal Beliefs & Interpretation of Events:

(Specify the content, mode of onset and degree of fixity of any abnormal beliefs a) in relation
to the environment, e.g. ideas of reference, misinterpretations or delusions; being treated in a
special way, persecuted, or the subject of an experiment b) in relation to the body c) in
relation to the self, e.g. delusions of passivity, influence, thought reading, or intrusion)

Abnormal Experiences Referred to Environment, Body, or Self:

(Environment: hallucinations and illusions; body: feelings of deadness, pain, other
sensations, somatic hallucinations; self: depersonalisation, awareness of disturbance in
mechanism of thinking, blocking, retardation, autochthonous ideas, etc; context: timing,
location, vividness, reality, etc.)

Cognition:
(e.g. orientation; attention & concentration; memory; intelligence)

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Insight & Judgement:

Interviewer’s Reaction to the Patient:*

SUMMARY:
(descriptive, objective, impartial)

● Reason for referral:

● Present illness:
● Personal history:
▪ Family history
▪ Personal history
▪ Childhood
▪ Occupations
▪ Marriage & children
▪ Previous personality
▪ Physical illness
▪ Previous mental illness
● Physical examination:
● Mental state:
● Investigations:
● Treatment & progress:
● Diagnoses (ICD-10):
● Prognosis:
● Care plan:
● Condition on discharge:
FORMULATION:
(Name, age, occupation and marital status; nature of onset, duration of present illness and its
course. Symptoms and signs; differential diagnoses; aetiology – why him/her? Why now?;
investigations; treatment; prognosis)

- Appendix 1.

Assessment of Early life Experience for High Risk patients:

If the patient report amnesia for most of their childhood there must be strong suspicion that
there have been events too painful to remember which have been actively obliterated.
Significant events, which probably will have influenced the person’s early development,
coping strategies, personality, relationship patterns and vulnerabilities, are as follows:

● Puerperal illness of the mother, which led to actual separation or subtle deficiencies in
early maternal care.
● Siblings born in rapid succession: pregnancy can interfere with the mother’s ability to be
receptive to her infant’s hostility towards its unborn sibling. This can lead to suppression
of feelings of rivalry and jealousy in the child, mistakenly reported as lack of jealousy.
● Twinship stresses the mother, twins, and all the family. Rivalry between twins and their
separate development may be obliterated in many ways if the parents find it too painful
and complex to deal with. Its reported absence is abnormal.

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● Death of parent and bereavement reactions can have a lasting effect. Who helped the
subject to mourn?
● Chronic illness, especially mental illness of a parent. Was it a family secret? What help
did the family have from outside? Who became the ‘parental child’?
● Parental strife and separation inevitably lead to divided loyalties. A mother who cannot
separate from a violent partner exposes her children to confusion. They want to but
cannot protect her and they cannot understand why she does not leave to protect herself.
● Single parenthood: perhaps poverty, lack of emotional support, frequent changes of
sexual partner with an increased risk of child abuse by partners.
● A frequent change of domicile – ruptures peers relationships and disrupts schooling.
● Bullying at school suggests poor self-esteem, poor social skills, and insecure early
attachment pattern.
● Frequent hospitalisations: separations, painful operations, disruption of schooling, and
peer relations, overanxious or disengaged parents.
● Major environmental failure: in and out of care, foster homes, children’s homes, childhood
sexual and physical abuse, neglect, emotional separation.

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Appendix II.

Sexual History:
● Age at puberty (voice breaking, shaving, menarche);
● Age at which first ejaculation occurred;
● Age at first masturbation – how this was regarded – fantasies – anxieties;
● Attitudes of parents to sexual matters;
● Sexual seduction or childhood sexual abuse;
● Any unusual sexual preferences – fantasies – activities;
● Homosexual or heterosexual orientation (fantasies, desires, and experiences);
● Any gender dysphoria, including non arousing cross-dressing
● Previous sexual experiences and relationships, including painful or traumatic ones;
● Current sex life (if any) – marital, extramarital, visiting, or cohabiting;
● Current frequency of masturbation;
● Level of sexual drive – any changes during this illness;
● Contraception, safe sex, sexually transmitted diseases;
● Sexual dysfunction – desire, arousal, or orgasm – partner satisfied;
● Discrepancy in sexual interest between partners;
● Menopause, hysterectomy, hormone replacement.
Appendix III.

Marital and Relationship History

● Age at first intercourse;
● Number of previous engagements or serious relationships;
● Difficulties in these and reasons for break-up;
● Age at present marriage (or cohabitation) – reasons (e.g. pregnancy);
● Age, occupation and personality of partner;
● Quality of relationship – threat of separation or divorce;
● Reaction of partner to patient’s present illness;
● Communication, negotiation of differences, ability to confide, empathy;
● Dominance, submission, distance, trust, fidelity, jealousy;
● Problems, past and present, arguments, violence;
● Death of spouse, separation (temporary or permanent), or divorce;
● Changes in sexual activities during relationship (e.g. ageing effects);
● Obstetric history – pregnancies, live births, terminations and miscarriages.

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