Psychiatric history

Introduction – whole name and role

Presenting complaint

Family history

For each family member:

- Age, or age at death and dates and cause of death

- Occupation
- Type of person
- Relationship with patient
- Amount of contact
- Mental health
- Physical health

Personal history

- Education – type of school/pupil, relationships with others, bullied or bully, higher

education, age finished, qualifications

Occupational history

- Periods of employment/unemployment, what jobs, how long in each role, reason for
change

Psychosexual history

Relationship status, relationship history:

- Any traumatic or abusive experiences in or out of a relationship
- Type of relationships/ length/ quality
- Sexual and marital history
- Details of current relationship if any
- Menstrual history (anorexia)
- Pregnancies and terminations, miscarriages
- Details of children
- Abusive experiences

Social history

- Housing, finance, social support, friendships, activities of daily living

Forensic history

- Any offences, convictions, probation, custodial sentence (inc. duration and type of
prison)

Medical history

- FULL DETAILS
- Significant medical problems – dates and treatments
- Current medication and allergy
Substance use/drug and alcohol history

- Smoking (can alter the metabolism of some medications)

- History of each substance used – date of onset, amounts taken, money spent, method of
administration
- Changes in patterns of use
- Periods of abstinence
- Effect on life
- Evidence of dependence

Past psychiatric history

- Take with presenting complaint or just after

- All episodes of illness – date, duration, treatment.
o Treatment – doses and type of psychological therapy and outcome
- Name of hospitals and those involved in management
- Any episodes of self-harm, suicidal thoughts/attempts

Premorbid personality

- Hobbies and interests

- Type of character
- Type of friendships
- Mood (pessimist/optimist)
- Religion/morals
- Ability to trust others
- Traits such as: impulsivity, worrier, dependant