Psychiatric History-Taking

Self-Harm

Triggers, type of self-harm, severity of harm

Delusions

Fixed false beliefs held involuntarily

Hallucinations

Incorrect sensory experience

Thought Disorders

Derailment, tangientiality, neologisms

Negative Symptoms of Psychosis

Amotivation, social withdrawal, blunt affect

Catatonia

Involuntary psychomotor abnormalities

Medical Complaint

As interpreted by the patient e.g. pain

Psychiatric Drugs

Which drugs, who prescribes them, effect

Admissions

When, why, length of stay, treatment received

Impact

On work and relationships

Aggressive behaviour

Circumstances, context, injury sustained

Criminal Charges / Convictions

Probation, jail time, fines

Systems Review

Medical issues may mimic psych problems

Past Medical Issues

Especially chronic disease

Medications

May affect mood / limit psychiatric treatment

Mental Illness

Psychiatric treatment, self-harm, suicide

Deceased Family Members

Circumstances, patient's response, effect

Have an index of suspicion; find out longitudinal and specific information with details and examples

Substances Used

Alcohol, marijuana, amphetamine, opioids, others

Amount Consumed

Period & pattern of abuse

Tolerance

Amount needed to reach the desired effect

Withdrawal Symptoms

What symptoms, severity

Attempts to Cut Down

Level of success, length of abstinence

Salience of Abuse

Time spent obtaining, using or recovering from

Complications

Physical / psychological

Impact on Work / Relationships

Regrets, extreme situations

Pregnancy, Delivery

Known complications

Childhood

Milestones, neglect / abuse / trauma

Schooling

Where, what level reached

Separations / Losses

And their consequences

Relationships and Support

Family, friends

Coping Strategies

Response to stress and adversity

Work history

Current and past jobs

Marital / Relationship History

Current and past relationships

Current interests

Level of continued enjoyment