History taking

Aashish Parihar
Assistant Professor
CON, AIIMS
Jodhpur
 History taking
Prerequisite for history taking
• Logistics of interview setting- seating arrangement, safety, privacy and
undisturbed environment.
• Greet the patient
• Explain the purpose of interview
• Explain the focus of interview
• Seek consent
• Informant need to be involved after getting permission from client
• Sensitive issues need to be asked very carefully and with great skill
• Maintain confidentiality
 History taking
Criteria for a good quality history:
• Systematic and coherent with appropriate headings
• Comprehensive with positive findings and relevant negative findings.
• Reflect the clinical relevance and priorities
• Unnecessary details should be avoided
• Multidimensional approach
 History taking
Component of history:
1. Identification Data
2. Chief complaints
3. History of Present Illness
4. History of Past Illness
5. Family History
6. Personal History
7. Premorbid Personality
 History taking
Component of history:
1. Identification Data
• Name and alias
• Age and Date of Birth
• Gender
• Religion
• Marital Status
• Occupation
• Socioeconomic status
• Family type
• Mother tongue
• Informant History…….
 History taking
Component of history:
1. Identification Data
• Informant History……. (Tabular form)

Whether
Duration of Reliability
S.N. Name Relationship staying with
relationship Status
client (Yes/No)
 History taking
Component of history:
2. Chief complaints
• Complaints should be recorded in verbatim response.
• Complaints must be supported with duration and severity.
• All the complaints need to be in chronological order.
Note: complaints made by patient and informant must be recorded separately.
 History taking
Component of history:
2. Chief complaints
• Example-
More talkative X 15 days
Abusive and aggressive behavior X 10 days
Decreased sleep X 10 days
Decreased appetite X 10 days
Refused to occupational functioning X 15 days
 History taking
Component of history:
3. History of Present Illness
History of present illness should cover the following points for the chief
complaints-
• Duration: Days/ Weeks/ Months/ Years
• Mode of Onset: Abrupt (<48 Hrs.)/ Acute (<1 week)/ Subacute (1-2 week) /
Insidious (within a few weeks)
• Course: Continuous/ Episodic/ Fluctuating/ Deteriorating/ Improving/ Unclear
• Intensity: Same/ Increasing/ Decreasing
• Precipitating Factors: Yes/ No if Yes explain
 History taking
Component of history:
3. History of Present Illness
• A narrative description of Symptoms and distress must be accounted along with
associated symptoms, biological dysfunction, any treatment and lastly social and
occupational dysfunctioning.
• Treatment History-
It should cover -
Drug name, dose, route and side effects
ECT
Psychotherapy
Rehabilitation
 History taking
Component of history:
4. History of Past Illness
• History of past medical illness: Absent/ Present
• Past Surgical/ operation/ accident: Absent/ Present
• Past Psychiatric history: Absent/ Present
If any one of the following is answered in present then record the following facts:
Nature
Duration
Treatment
Outcome of the illness
 History taking
Component of history:
5. Family History
• Family history must be supported by Genogram (Family tree) of at least three
generation from both father and mother side.
• After genogram following points must be recorded:
1. Consanguinity in parents: Absent/ Present
2. Step Parents: Yes/No
3. Adopted: Yes/No
4. Siblings: Any Psychiatric Illness
5. Any history of suicide
6. Relationship
7. Any stressor
 History taking
Component of history:
5. Family History
Genogram:
 History taking
Component of history:
6. Personal History
Sub component of personal history-
x Self Harm History
i. Perinatal History
xi Addiction History
ii. Childhood History xii Forensic History
iii. Educational History xiiiSocial History
iv. Play History xiiiHistory of abuse and
v. Emotional Problem during adolescence violence
vi. Pubertal History
vii. Obstetrical History
viii.Occupational History
ix. History of Procreation
 History taking
Component of history:
6. Personal History
i. Perinatal History
• Antenatal period: Maternal Infection/Exposure to radiation/ checkups
• Intranatal period: Mode of delivery/Any complication
• Birth: Full term/ premature/ postmature
• Birth Cry: Immediate/ delayed
• Birth Defects: Yes/ No if Yes, Specify……..
• Postnatal Complication: Cyanosis/ Convulsions/ Jaundice/ Infection/ any
other
 History taking
Component of history:
6. Personal History
ii. Childhood History
• Primary Caregiver:---------------------
• Feeding: Breast feed/ Artificial mode of feeding
• Age at weaning: --------------------
• Developmental Milestone: Normal/ Delayed
• Behavior and emotional: Thumb sucking/Temper tantrum/ Stuttering/ Head- problem
banging/ Body rocking/ Nail-biting/pica/ Enuresis/ Morbid fears/ Night terrors/
Somnambulism
• Illness during childhood: Especially CNS infections/ Epilepsy/ Neurotic disorders/
Malnutrition
 History taking
Component of history:
6. Personal History
iii. Educational history
• Age at beginning of formal education: ----------------
• Academic performance: ----------------
• Extracurricular activities: ----------------
• Relationship with peers and teachers: ----------------
• School Phobia: Yes/ No
• Conduct disorders: Yes/ No
• Reason for termination of studies: ---------------
 History taking
Component of history:
6. Personal History
iv. Play History
• Game played: --------------- (at what stage and with whom)\
v. Emotional problem during adolescence
• Running away from home/ Delinquency/ Smoking/ Drug taking/ Any other
vi. Pubertal History
• Age at appearance of secondary sexual characteristics:-------
• Anxiety related to pubertal changes: Yes/No
• Age at menarche: -------
• Reaction to menarche:--------
• Regularity of cycle and period of flow: ------& -----
• Abnormalities: --------------
 History taking
Component of history:
6. Personal History
vii. Obstetrical History:
• LMP: -------------------
• Number of Children: -------------------
• Any abnormality associated with pregnancy, delivery, puerperium: --------------
• Termination of pregnancy, if any: ------------------
• Menopause: -------------------
 History taking
Component of history:
6. Personal History
viii.Occupational History:
• Age at starting work: ------------------
• Job held in chronological order ------------------
• Reason for changes: ------------------
• Current job satisfaction: ------------------
 History taking
Component of history:
6. Personal History
ix. History of procreation:
• Genogram
• Type of marriage: Self choice/ Arrange
• Duration of marriage: -------------------
• Interpersonal and sexual relation: -----------------
• Extra marital relation, if any: ---------------------
 History taking
Component of history:
6. Personal History
x. Self harm History: Not applicable/applicable
• No. of attempts with date
• Method and out come
• Suicidal ideation ever
Note each attempt must be recorded in following manner
S Preparatory act
. Reason/ like warning Type and Communication
Date circumstances/ lethality of Outcome
N notes/ suicidal after attempt
stress factor method
. note
 History taking
Component of history:
6. Personal History
xi. Addiction History: Not applicable/applicable
Type/
Quantity/
Substance brand/ frequency Time period Current use Dependence
mode

• Mode of onset
• Impact:
• Withdrawal symptoms
• Treatment received
 History taking
Component of history:
6. Personal History
xi. Forensic History: Not applicable/applicable
Number
Nature Yes No Reason with dates
of times

• Mode of onset
• Impact:
• Withdrawal symptoms
• Treatment received
 History taking
Component of history:
6. Personal History
xii. Social History:
• Social Support:
• Family support
• Accommodation
• Financial Situation
• Domestic activities
• Outdoor activities
• Any disadvantages of social condition
 History taking
Component of history:
6. Personal History
xii. History of violence and abuse:
 History taking
Component of history:
7. Premorbid Personality
• Interpersonal relationship: Extrovert/ Introvert
• Family and social relationship: ------------------------
• Use of leisure time: ------------------------
• Predominant mood: Optimistic/ Pessimistic/ Stable/ Fluctuating/ Cheerful/ Despondent
• Usual reaction to stressful events: -----------------------
• Attitude to self and others: -----------------------
• Attitude to work and responsibility: -----------------------
• Religious belief and moral attitudes: -----------------------
• Fantasy life: ----------------------
• Habits
Eating pattern:
Elimination
Sleep
 History taking
Summary:
Important findings, clinical applicability.

Conclusion:
Problem faced during data collection
Further exploration of findings.