History taking

Demographic data:
Name:

Age:

Sex:

Marital status:

Occupation:

Address:

Religion:

Date of admission:

Date of taking the history:

Name of the informant and relationship to the patient:

Reason and source of referral:

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Chief complaint and duration:

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History of present illness:

Analyzing the chief complaint: (apply from SQUITARPS as possible)

Functional/social impairment?

Mood ?

Sleep ?

Appetite and weight ?

Hallucinations ?

Delusions ?

Suicide / homicide ?

Any medications taken for disease? Any side effects?

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Prepared by: Bijar Raziki

Family history:
Parents:

Names Are they divorced?

Ages: If dead:
Occupations: Place of death:
Health: Cause of death:
Education: Age of parent when
died:
Personality: Age of patient when
Relationship: parents died?

Siblings:

Name / sex
Age:
Occupation:
Health:
Education:
Personality:
Marital status:
Social and
economical
status
Relation with
patient and his
feelings toward
them

Relatives:

Any abnormal personalities?

Any mental disorders?

Epilepsy?

Alcoholism?

Home atmosphere? Where? With who? Overcrowded?

Personal history:
Pregnancy and birth:

Date and place

of birth
Mother condition
during birth
Delivery:
Complications:

Early childhood:

Feeding way
Developmental Attachment Talking Walking Bowel control Bladder
milestones: control
Behavior Playing Hostility hyperactive Relation with family
(alone)
Neurotic Bed Temper Nail biting Thumb Night Sleep walking
symptoms wetting tantrum sucking terror
Stuttering Fears Tics Mannerism

Adolescence and adulthood:

Social life ? prefer isolation or peer group

Difficulties? Crises ?

Fantasies ?

Educational history:

School Age of starting Age of finishing Name of school Reaction to school

Phobia/ truancy Attitude to Peers Achievement/ Higher education?

teachers and others ambitions

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Occupational history:
Age of starting List of jobs Regularity Satisfaction Economy status

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Menstrual history:
Start Finish Regularity Duration Last one pain PMS

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Sexual history:
Orientation Experienced ? Masturbation Ant worries or Fantasies and any
(homo/hetero) when? guilts? deviations or
dysfunctions

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Marital history:
1. Marriage? Age date number
2. Partner: age occupation personality health
3. Sex: mode of intercourse orgasm and impotence
4. Satisfaction ?
5. Contraception
6. Abortions
7. Any extramarital relationship
8. Children (age, sex, health, personality and relationship)

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Alcohol Smoking Drugs

Quantity Quantity Quantity

Frequency Frequency Frequency

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Past medical history

Past surgical history

Past drug history

__________________________________________________________________________________

Past psychiatric history

Date Duration Symptoms Treatment

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Forensic history
Illegal acts Court Prison

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Present social circumstances:

Living standards Interests and hobbies Financial status

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Premorbid personality:
Mood: cheerful-sad, tense-calm, optimistic-pessimistic, stable-unstable, apathetic-inhibited.
Character: hesitant, self confident-shy timid, tolerant-not, expressive, trusting-suspicious,
irritable-not, sensitive-not, jealous-not.
Moral: selfish, or altruistic, religious, rigid
Energy; energetic, initiative, sluggish, or fluctuant
Socially; Introvert or extrovert
Fantasy life; Is he a day dreamer
Habit and hobbies

Extra-notes:
 mental state examination
Age:
Gait:
Dressing:
Appearance Posture:
Facial expression:
Weight:
level of alertness:
Eye contact and cooperation:
Overall level of activity:
Behavior
Disinhibited behavior?
Withdrawal?
Aggression?
Rate:
Difficulty speaking?
Neologisms?
Speech Flow of speech:
1. Thought blocking?
2. Flight of ideas?
Full range of affect?
restricted range of affect?
Labile affect?
Flat affect?

Euthymic?
Dysthymic?
Euphoric?
Mood / affect
Anxiety?
Depression?
Mania?

Suicidal ideation?

Somatic symptoms?
thought processing:
1. Rapid or slow
2. Tangentially
3. Circumstantially
Thoughts 4. Goal-directed
5. Clang associations
6. Neologisms
7. Loose
8. Incoherent (word salad)
 mental state examination
Thought content:
1. Obsessions
2. Delusions
3. Preoccupations
4. Suicidal
5. Homicidal
hallucinations?
Perceptions Which type?
orientation to:
1. Time
2. Place
3. Person

Attention and concentration:

Serial 7 test:

Memory:
Cognitive 1. Short term:
2. Recent term:
functions 3. Remote term:

Calculations:

Reasoning (judgement)

Abstraction:
1. Similarities
2. Proverb
does he know he is ill?

Insight Is that illness physical or mental?

Does he think that he need treatment?