Psychiatric history

1. personal history same items plus education, religion, circumstances of referral ( compulsory
or voluntary )
2. Complaint in patient or relative’s own words
3. HPI : open question (can you tell me what has been happening?) then establish the time the
illness started and when this episode started
4. What he thinks caused his illness, what improves and what worsens it ?
5. What is the effect of his illness on his daily life/ work/ relationships
6. Follow up questions abt other symptoms
7. Ask abt mood/ sleep and appetite even if they seem normal
8. Ask about thoughts of harm to self or others
9. Previous psychiatric illness; date, symptoms , diagnosis, treatment and wether ttt was
voluntary or compulsory
10. Previous psychiatric hospitalization, psychotropic drug intake (note the dosage of the drug
and wether it helped or not)
11. Drug abuse, alcohol or dependence
12. Ask abt any serious illness, any previous surgery, all current medications.
13. Family history : parents and sibling’s mental health and their relationship with the patient
14. Family history of psychiatric illness, drug abuse, forensic encounters and medical illness.
Some details in personal history:
* Educational: academic degree, wether he had friends or not, bullying, school refusal
* occupational : Jobs in chronological order, reason of changing, work satisfaction and
relationship with colleagues
* Sexual and marital history: age of puberty, masturbation, sexual practices, marriage as
regards age of marriage, duration, children, relationship and quality, abuse.
* For females ask abt menstrual pattern, contraceptives, previous pregnancies.
* Substance Use (Alcohol or tobacco )
* PREMORBID PERSONALITY : how would you describe yourself before you became unwell?
How would your friends describe you? ( you can ask an informant who’s familiar w the patient),
ask about interpersonal relationship, how does the patient cope when things go wrong, how he
uses leisure time, his predominant mood, attitude to self and others, attitude to work and
responsibilities, religious beliefs and habits (food, alcohol, drugs, sleep)