History Taking

Introduction
 Introduce yourself (including your name and your role)
 Explain the purpose and how long you have to interview the patient.
 Gain consent to take a history and ask for permission to take notes.

a. Personal Information
Name, Age, Gender, Marital status and children, Occupation (present and past), Religious and Ethnic
background, Home town.
b. Source of Referred
Describe the pathway of access,

c. Presenting (Chief) complaint/s and duration

Patient’s description of the problem. (when lack of the insight about the illness, concerns of family
members or details of the referral should be recorded)

d. (Presenting)Problem Related History

 Generally, contains information from the time the patient was last healthy until the time of
evaluation.
 Nature and severity of the problem and the time patent’s concern.
 Onset of symptoms-sudden or insidious
 Development and progression of symptoms over time
 Etiological factors – Biological, Psychological and Social
 Impact of symptoms on life
 Describe level of functioning/changes– activities of daily living, household activities,
educational and occupational functioning and social interactions.
 Response to treatment

e. Past History
a. Medical History
 Current or previous medical illnesses
 Past surgical procedures
 Head injuries and previous cranial surgery, neurological conditions (e.g. epilepsy) and
endocrine abnormalities
 And medication usage
 b. Psychiatric History
 The past, Previous or ongoing psychiatric diagnoses
 Dates and duration of previous episodes of mental illness
 Details of previous hospitalization and treatment including medications, psychotherapy and
electroconvulsive therapy
 Response to treatment and about side effects.

f. Family Related history

 Presence of psychiatric illness, substances use or suicide in family members.
 Quality of family relationships. (Collect information about parents, siblings and other)
 significant relatives. (How do you get on with your family?’, ‘Are there any recent significant
events that have occurred in the family?)
 Brief medical history of family: (Are there any medical conditions which run in the family?)

g. Personal History
Includes Early childhood, Education, Employment, Relationships, Sexual history, Substance use,
Forensic history.

h. Social History
 current accommodation (state of housing, heating, living conditions),
 social support (friends and family),
 financial circumstances (any debts or benefits) and
 hobbies or leisure activities.