- Diagnosis
- History
- Examination
- Investigations
- History
- Management
- Procedures
Psychiatric History-Taking
Presenting Complaint
Low Mood
SADAFACES
High Mood
FIDGET
Suicidality
SADPERSONS
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
Past Psychiatric History
Forensic History
Past Medical History
Medications
Family History
Substance History
- 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
Developmental History
Social History
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