General Santos Doctors’ Medical School Foundation Inc.

Bulaong Subdivision, Barangay West, General Santos City 9500

Tel No.: (083) 302-3507, Telefax No.: (083) 552-9793

Psychosocial Assessment: HISTORY

SUBMITTED BY:

Danika Kaye Macababat, SN

Grazylle Mae Abrasaldo, SN

Mary Elaine Maghanoy, SN

Zheriz Vhien Sendico, SN

Lide Arna Campos, SN

Shaemmie Galos, SN

Kyla Via Javier, SN

Marjorie Lague, SN

Gwyneth Lugo, SN

Aldrene Opiña, SN

Kylle Alimosa, SN

Lyka Abella, SN

FEBRUARY 2024
 Client with Obsessive-Compulsive Disorder (OCD)

Instruction: Write down questions specially on psychosocial assessment then provide rationale.

I. Biographical Data
Questions Rationale

What is your name? This helps check if the client is able to

know his/her name. Obtaining the patient’s
full name is essential for accurate
identification and maintaining records.

What is your date of birth?
To confirm the client's identity and ensure
that the treatment and interventions are
appropriate for their age.
Age can influence the onset and
manifestation of OCD symptoms. It is also
relevant for understanding the
developmental context of the disorder.

What is your age? Age can be a factor in the onset and

progression of OCD symptoms. It helps
establish a timeline for symptom
development and guides treatment
planning.

What is your current address? Knowing the current address is essential

for administrative and contact purposes. It
helps in sending appointment reminders,
relevant documents, or coordinating care.

What is your gender identity? Gender identity can influence the

manifestation and expression of OCD
symptoms. Understanding the client’s
gender identity promotes culturally
sensitive care and helps address gender
specific concerns related to OCD.

What is your relationship status? Do you have To determine patient's social support
children? system.

Can you describe your educational and/or To assess patient’s health literacy and
occupational background? identify potential work-health related risks
or stressors.

What is your religion? Religious or spiritual beliefs may influence

 coping strategies and treatment
preferences. Understanding the patient’s
religious background helps provide
culturally sensitive care.

II. History of Present Health Concern

Questions Rationale

Can you describe any specific thoughts or This question allows the client to share
concerns that have been occupying your mind their thoughts without directly mentioning
recently? OCD. It provides an opportunity for them
to express their concerns in a
non-threatening way.

How do these thoughts impact your daily Understanding the practical impact of
activities and routines? obsessive thoughts on the client's life helps
in gauging the severity and functional
impairment without focusing solely on the
obsessions.

Have you noticed any particular rituals or This question gently explores compulsive
behaviors that you engage in to manage or behaviors without directly labeling them as
alleviate these thoughts? such. It allows the client to describe their
coping mechanisms.

In what situations or environments do you Identifying triggers helps in understanding

find these thoughts and behaviors more the context of the client's experiences,
pronounced? contributing to a more nuanced assessment
without directly confronting the distressing
elements.

How have your relationships with family and This question assesses the impact of OCD
friends been affected by your current on social functioning and relationships,
experiences? providing insights into the broader
psychosocial context.

Do you feel comfortable discussing these Assessing the client's comfort level in
concerns with others, or do you tend to keep sharing their experiences helps gauge their
them to yourself? willingness to engage in treatment and
support, while also addressing potential
feelings of isolation.

Can you share any instances where you This question focuses on resilience and
successfully managed or controlled these coping strategies, encouraging the client to
thoughts and behaviors, even if briefly? reflect on positive aspects of their
experience and potential strengths in
 managing their condition.

III. Past Health History

Questions Rationale

Have you ever experienced symptoms of Knowing when the symptoms started helps
OCD before? When did the symptoms start? in understanding the natural history of the
illness, which can inform the diagnosis and
treatment decisions

This provides insights into the severity and

recurrence of the patient's condition

Were you diagnosed with OCD prior to this This helps in understanding the patient's
session? mental health trajectory and informing
current diagnosis.

If so, did you undergo any medications or Understanding the treatments and
treatment? Were they helpful? medications received during
hospitalizations provides insights into the
patient's mental health management and
response to interventions

Can you identify any specific events or This question aims to uncover potential
situations that seemed to trigger the onset of precipitating factors that may have
your symptoms? contributed to the development of the
individual's psychological disorder

Have you ever been admitted to a psychiatric This question aims to establish if the
hospital? patient has a history of psychiatric
hospitalization.

Were you admitted informally or under a Understanding the legal status of the
section of the mental health act? patient's admissions provides insights into
their level of risk and the nature of their
hospitalizations
IV. Family Health History
Questions Rationale

This helps to identify any hereditary health

Did your parents or grandparents have any conditions that may run in the family.
health problems?

Do you know if your parents or grandparents This question aims to gather

took medicine on a regular basis? If so, for information,specifically in relation to
what? Did they use home remedies? medication usage and the use of home
remedies.

Have any of your close family members been This question aims to assess the potential
diagnosed with OCD? presence of hereditary risk factors in the
patient's family.

(IF YES) When were they diagnosed? This question aims to know the year of
diagnosis.

Do any of your immediate family members This question aims to assess the potential
have a history of cardiovascular disease or presence of hereditary risk factors for
stroke? cardiovascular disease in the patient's
family.

Has anyone on your Paternal or Maternal side This question aims to assess the potential
been diagnosed with a genetic disorder? (e.g. presence of hereditary genetic disorders in
Down syndrome (Trisomy 21).FragileX the patient's family, which may have
syndrome,Klinefelter syndrome,Triple-X implications for the patient's own risk of
syndrome,Turner syndrome,Trisomy developing such a disorder.
18,Trisomy 13).
Has anyone on your Paternal or Maternal side This question provides valuable
died due to a disease (e.g. cancer, diabetes, information regarding potential inherited
stroke)? diseases or genetic predispositions that may
increase an individual's risk of developing
certain conditions.

This question helps to seek additional

Is there anything else you would like to tell
information and may give guidance about
me about your life or health concerns in your
health concerns in a patient's family.
family?

V. Developmental Stage
Questions Rationale

How do you feel about the level of trust and This question explores the client's sense of
connection in your relationships, especially trust and security in relationships,
with caregivers or significant others? providing insights into early attachment
experiences and potential sources of
emotional support.

Can you share your thoughts on your ability to This question delves into the client's sense
make choices and decisions in your life? How of autonomy and self-efficacy, uncovering
do you handle situations where you feel any challenges related to independence and
restricted or criticized? self-expression.

How do you approach setting goals and taking
initiatives in your life? How do you handle
feelings of guilt or self-blame when things
don't go as planned?
Exploring the client's approach to
goal-setting and initiative provides insights
into their developmental stage, addressing
any struggles with taking proactive steps or
coping with setbacks.

How do you perceive your achievements and
competence in various areas of your life, such
as school, hobbies, or activities? How do you
handle challenges that may make you feel less
capable?
This question aims to uncover the client's
self-perception regarding competence and
industry, highlighting potential sources of
pride or areas where they may feel inferior.
How would you describe your sense of Exploring the client's sense of identity and
identity and the values that guide your life? values addresses the critical developmental
How do you navigate challenges that might task of adolescence, shedding light on
create confusion about who you are? potential struggles with identity formation.

How do you approach and experience This question explores the client's
intimacy and connection with others? Are experiences with intimacy and
there barriers or challenges you encounter in relationships, addressing potential issues
building and maintaining meaningful related to forming and sustaining
relationships? connections with others.

How do you feel about your contributions to This question delves into the client's sense
the well-being of future generations or your of generativity, exploring their
community? Do you experience a sense of contributions to society and addressing
purpose and fulfillment in your life? potential feelings of stagnation or lack of
purpose.

As you reflect on your life, how do you This question addresses the existential
perceive the meaning and integrity of your reflections of late adulthood, providing
journey? How do you cope with any feelings insights into the client's sense of life
of regret or despair? satisfaction, meaning, and resolution of past
experiences.

VI. Spiritual Beliefs

Questions Rationale

Can you share any spiritual or religious Understanding the client's existing spiritual
beliefs that are important to you? framework helps you appreciate their
perspective and potential sources of
comfort or distress.

How do your spiritual beliefs influence your This question explores the practical impact
daily life and decision-making? of their beliefs and how they may intersect
with their OCD symptoms.

Do you find that your obsessive thoughts or This can help identify if there are specific
compulsive behaviors are connected to your triggers or themes related to spirituality
spiritual beliefs in any way? that contribute to their OCD symptoms.

Have there been any changes or conflicts in Changes in belief systems might be related
your spiritual beliefs since the onset of your to the distress caused by OCD, and
OCD symptoms? exploring this can provide insights into the
client's experience.
 Do you use any spiritual practices or rituals as Understanding coping mechanisms is
a coping mechanism? crucial, as some rituals or practices may be
adaptive while others may exacerbate
symptoms.

Have you discussed your OCD with any This explores the client's support network
spiritual or religious leaders? If so, what was and how their spiritual community may be
their response or guidance? involved in their journey with OCD.

How do you reconcile any moral or ethical OCD can sometimes bring about moral or
concerns that may arise due to your OCD ethical obsessions, and exploring this can
symptoms and your spiritual beliefs? help understand the client's internal
struggles.

Are there any specific religious or spiritual Identifying specific teachings can help in
teachings that bring you comfort or tailoring interventions that align with their
exacerbate your anxiety? belief system and avoid potential triggers.

Do you feel a need to seek reassurance from Reassurance-seeking is a common

your spiritual beliefs to alleviate anxiety? compulsion in OCD, and understanding if
it extends to their spiritual beliefs is
important for intervention planning.

How do you navigate any conflicts between This question explores the client's ability to
your spiritual beliefs and the integrate therapeutic approaches and
cognitive-behavioral therapy (CBT) whether there are any conflicts that need to
techniques we are using to address your be addressed in the therapeutic process.
OCD?

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