History taking in Psychiatry - Dr.

Reza Parker
Basics :
Phrase questions simply and clearly
Be patient, do not rush, use silence appropriately especially in those with depression
Be sensitive and if patient cries, offer tissue, glass of water. DONT Touch the pt*
Recognise patients' verbal and non-verbal cues
Use normalization and generalization
Most importantly- Pt's always lie.
____________________________________________________________________________
Name DOB
Age Occupation
Marital status

1. Circumstances of referral: (why was the pt referred)

2. Presenting complaints : Use the pts own words and/or as described by them
3. History of presenting complaints:
a. A description of the symptoms and their duration, including:
b. how the symptoms began, and how the symptoms changed with time (e.g.
Increasing gradually or stepwise /remained the same/episodic in nature)
c. Changes in biological functions (e.g. Sleep, appetite, weight)
i. affect of symptoms on patients relationships, day to day activity and work
ii. association between symptoms and any stressors or life events
iii. Any other relevant information
4. Family history:
a. age and occupations of parents and the parents relationship with one another
b. general information about siblings the patients relationship with his
c. parents and siblings
d. social standing of the family
e. history of psychiatric illness, suicide or substance misuse in the family
5. Personal history:
a. Antenatal and birth history
b. Early developmental history
c. Health in childhood
d. Occupational history
e. Marital history
f. Sexual history
6. Substance use:
a. History of substance use : alcohol, nicotine, cannabis, other drugs of use
b. Duration of use : amount used at present and frequency of use
c. Associated problems (e.g. legal/financial/social problems secondary to substance
misuse)
7. Past medical/surgical history:
 8. Past psychiatric history:
a. Does the patient have a past history of psychiatric illness? When?
b. Was the illness episodic? Or was the patient continuously unwell?
c. Nature of treatment received, and response to treatment? why ?
d. Drug adherence?
9. Forensic history
a. Arrested/ Prosecuted find the common element.

Mental Status Examination

1. Appearance and behavior:

a. General appearance
b. Posture and movement
c. Attitude towards examiner
2. Speech:
a. Rate of speech
b. Flow of speech
c. Content of Speech
d. Volume
3. Mood:
a. Anxious
b. Depressed
c. Elated
d. Irritable
e. Angry
4. Content of Thought:
a. Pre occupations and/or worries?
b. Ideas and plans of suicide?
c. Ideas and plans of suicide?
d. Obsessional ideas/impulses/images and compulsive rituals?
e. Delusions/overvalued ideas?
5. Disorders of Perception:
a. Hallucinations auditory, visual, olfactory, gustatory, tactile
b. Illusions
6. Cognitive Functions:
a. General: Alertness and awakeness
b. Orientation: Time, Place and Person
c. Registration: Three objects (apple, table and coin)
d. Attention
e. Recall: the three objects
f. Language: Naming and Repetition
g. Calculation: Division and Subtraction
h. Abstraction: Proverbs and Similarities
i. Memory: STM and Long-term memory
 j. Praxis: Wave good-bye and Comb hair
7. Insight and Judgement
a. Awareness of disease:
i. Do you consider that you are ill in any ways?
ii. Why have you come into hospital?
iii. Do you have a physical or a mental illness? What is it? What is your
explanation of these experiences?
b. Right or wrong?
___________________________________________________________________________

It might seem like a lot but you cover all aspects fairly quickly (30-90mins depending)