HISTORY

I. Identifying Data
Name
Age
Sex
Civil Status
Occupation
Nationality
Handedness
Religion
Educational Attainment
Address
Date of Consultation

II. Pre-morbid Personality and Level of Functioning

III. Chief Complaint

Verbatim
According to the patient
According to the relative

IV. HPI
Onset of symptoms
Duration and frequency
Severity
Precipitating/ relieving factors
Interventions done, if any
Other related symptoms
Timeline of events
Effect on functioning

V. Past Medical/ Psychiatric History

Medical co-morbidities, including maintenance medications: HPN, DM, asthma, allergies,
thyroid problems, seizures, head trauma, recent infections
Surgeries, if any
For female patients, LMP if still menstruating, OB code and indicate if had menopause (indicate
since when)
For Psychiatric History: year diagnosed, medications, compliance to medications and regular
consults with psychiatrist

VI. Family Medical History

Medical illnesses in the family
Psychiatric disorders in the family, including any addictions/ alcoholism
VII. Social History
Smoking
Alcohol beverage intake, if any
Use of any illicit drugs

VIII. Anamnesis

Pre-natal/ perinatal
Planned or wanted pregnancy
Pre-natal check-ups of mother
Any complications
Any intake of alcohol or illicit drugs during mothers pregnancy
Delivery: NSD or CS (indicate reason), full-term or pre-term
Complications post-delivery

Early childhood
Developmental milestones, if at par
Breastfed/ bottle-fed
Attachment figure/ primary caregiver
Toilet training
Temper tantrums

Middle childhood
Adjustment to school
Academic performance
Social skills (friends)

Late childhood/ Adolescence

Friends
Romantic Relationships
Experimentation with smoking, alcohol, illicit drugs
Rebellious or risk-taking behavior, if any
Sexual relationship/s

Adulthood
Social activity
Education
Relationship/ marriage history/ sexual history
Occupation
Religion
Legal history
Military history

IX. Review of Systems