Psychiatric History Taking

1. Introduction:
a. Patient’s Name/Initials: ______________________________________________
b. Age: ______________________________________________________________
c. Gender: ___________________________________________________________
d. Marital Status: ______________________________________________________
e. Occupation: ________________________________________________________
f. Religion: ___________________________________________________________
g. Location (Name of Hospital or Outpatient Clinic): __________________________
h. Date of the Patient’s Presentation: ______________________________________

2. Presenting Difficulty/Complaint (Including Duration):

Patient: “______________________________________________________________
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Collateral: “____________________________________________________________
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3. History of Presenting Difficulty:

a. Why has the patient presented now?
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b. What were the major symptoms leading up to the current presentation?

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c. For how long have the symptoms been present?

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d. Are the symptoms pervasive in nature (i.e. constantly present)? If not, how frequent are the
symptoms present?
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 e. Were the symptoms precipitated by anything (e.g. bereavement, loss of one’s job, etc)?
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f. Are the symptoms becoming more or less intense over time?

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g. What has been the impact of the symptoms on the patient’s life?
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4. Past Psychiatric History:

a. Does the patient have a history of previous contact with psychiatric service?
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b. At what age was the patient diagnosed with mental illness?

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c. Who diagnosed the patient with mental illness?

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d. What diagnosis was made?

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e. Number of previous admissions to a psychiatric hospital and the reasons for such admissions?
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f. Average length of admissions?

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g. When was the most recent admission?
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h. Any involuntary admission?

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i. Has the patient ever been treated with electroconvulsive therapy (ECT)?
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j. If the patient currently has depression, do they have a past history of hypomania or mania?
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k. Does the patient have a past history of self-harm?

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l. How many previous episodes of self-harm has the patient had?

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m. What was the first episode of self-harm?

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n. When was the most recent episode of self-harm?

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o. What forms of self-harm have been undertaken (e.g. overdose, self-laceration, attempted
hanging, attempted drowning, etc).
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p. Did the patient require stiches or other medical attention following any episode of self-harm?
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5. Family History:
a. Parental History:
I. What age are the patient’s parents (or their age when they died and the cause of
their death)?
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II. What are the occupations of the patient’s parents?

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III. If the parents are separated or divorced, when did they separate of divorce?
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IV. How would the patient describe their relationship with their parents?
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b. Siblings:
I. How many siblings does the patient have?
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II. What is the age range of the patient’s siblings?

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III. If any siblings are deceased, what age were they when they died, when did they die
and what was the reason for their death?
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IV. What position in the sibship is the person?

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V. How would the patient describe their relationship with their siblings?
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c. Family Psychiatric History:

I. Is there any family history of psychiatric illness in the immediate and distant family?
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 II. Do any family members have a history of inpatient psychiatric admission?
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III. Is there any known family history of self-harm or suicide?

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6. Past Medical and Surgical History:

a. Does the patient have a history of epilepsy, diabetes, asthma, head injury or any other
significant medical illness (i.e. Hypertension or Hyperlipidaemia)?
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b. Does the patient have a history of any operations?

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c. Does the patient have a history of an allergic reaction to any medication?

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7. Alcohol and Substance Misuse History:

a. Alcohol:
I. What age was the patient when they first consumed alcohol?
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II. Has the level of the patient`s alcohol consumption changed over time?
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III. Why does the patient consume alcohol (e.g. for pleasure, escapism, euphoria, to “feel
normal”, to reduce anxiety, to overcome withdrawals or as a compulsion in the situation
when they cannot control their intake)?
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IV. How many units of alcohol does the patient consume per week?
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V. Consider the criteria for alcohol dependency syndrome.

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 VI. Consider the CAGE Questionnaire.
a) Have you ever felt you should Cut down on your drinking? _______________________________
b) Have people been Annoyed you by criticising your drinking? ______________________________
c) Have you ever felt bad or Guilty about your drinking? ___________________________________
d) Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover
(Eye-opener)? ___________________________________________________________________

VII. Has the patient had any injuries under the influence of alcohol?
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VIII. When did the patient last consume alcohol and how many units did they take at that
time?
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IX. In the case of alcohol misuse/dependence, does the patient have a history of
engagement with any alcohol rehabilitation programme?
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b. Illicit Substances:
I. Does the patient have a history of using illicit substances?

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II. What age was the patient when they started using illicit substances?

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III. Which illicit substances has the patient used?

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IV. What quantity of illicit substances does the patient have a history of using?

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V. Any intravenous drug use? Has the patient ever shared needles with someone else?

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 VI. Why does the patient take illicit substances (e.g. for pleasure, escapism, euphoria, to
“feel normal”, to reduce anxiety, to overcome withdrawals or as a compulsion in the
situation when they cannot control their intake)?

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VII. When did the patient last use illicit substances and what quantity of illicit substances was
used at that time?

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VIII. In the case of illicit substance misuse/dependence, does the patient have a history of
engagement with any substance misuse rehabilitation programme?

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c. Prescription and Non-Prescription Medication:

I. Does the patient have a history of buying tablets such as benzodiazepines, hypnotics or
olanzapine ‘on the streets’, or misusing benzodiazepines or hypnotics from other
sources?

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II. Does the patient have a history of misusing prescription or non-prescription medication?

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d. ‘Head Shop’ Products:

I. Does the patient have a history of using ‘Head Shop’ products?

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e. Nicotine:
I. Does the person smoke?

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II. Since what age has the patient been smoking?

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III. Number of cigarettes/day?

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8. Current Medications:
a. Is the patient currently prescribed any medication?

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b. List the psychiatric medications first.

I. List antidepressants/antipsychotics/mood stabilisers first.
II. List benzodiazepines/hypnotics next.
III. List thyroid medication (if prescribed) next.
IV. List other medications after all of the above.

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c. DO NOT use trade names for medications. Give the doses of the different medications and
the daily frequency at which they are prescribed.
d. How would the patient describe their compliance with their prescribed medication (e.g. fully
compliant, intermittently compliant or non-compliant)?

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e. If the person is not fully compliant with their prescribed medication, what is the reason for
this (e.g. unpleasant side effects or the belief that they do not need the medication)?

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9. Personal History:
a. Birth and Development:
I. Was the patient born at full gestation, premature or post-mature?

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II. Was there any known instrumental intervention associated with the birth?

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III. Were there any complications associated with the pregnancy or the birth (e.g. umbilical
cord around the neck)?

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 IV. Where was the patient born and where did they grow up?

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V. Was the patient breast fed or bottle fed?

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VI. Were the developmental milestones normally attained?

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b. Childhood and Adolescence:

I. Would the patient describe their childhood as happy or unhappy?

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II. Does the patient have a history of significant traumatic events or childhood physical,
sexual or emotional abuse?

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III. Does the patient have a history of any significant childhood illnesses?

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c. Education and Literacy:

I. What age was the patient when they started school?

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II. What age and what in class was the patient when they left school?

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III. Does the patient have a history of frequent changes in school? If so, why?

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IV. Would the patient describe themselves as having been a good, average or weak student?

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 V. Does the patient have a history of bullying?

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VI. Does the patient have a history of truancy?

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VII. Did the patient have a good relationship with other children and with their teachers?

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VIII. Did the patient have any special educational requirements?

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IX. If the patient attended second level education, did they sit the Junior Certificate and
Leaving Certificate Examinations? Did they pass these exams?

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X. If the patient left school prior to completing second level education, why did the person
leave school early?

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XI. Did the patient attend third level education after leaving school?

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XII. Can the patient read and write?

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d. Occupational History:
I. Has the patient ever engaged in paid employment?

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II. At what age did the patient start working?

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 III. What jobs has the patient worked in?

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IV. Obtain the reasons if there have been frequent changes in employment.

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V. When did the patient last work or are they still employed?

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VI. If the patient is not currently employed, what was the reason for them leaving their most
recent job?

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VII. Did the patient enjoy their most recent job?

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VIII. If the patient does not work, do they receive disability allowance or other social welfare
assistance?

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e. Relationship History:
I. Quality and quantity of both romantic and non-romantic relationships?

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II. Is the patient currently married or otherwise involved in a romantic relationship? If so, for
how long?

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III. Is the patient happy in their current relationship?

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IV. Does the patient have a history of any significant relationship difficulties (e.g. physical,
sexual or emotional abuse)?

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 V. Would the patient describe themselves as heterosexual, homosexual or bisexual in
orientation?

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VI. Does the patient have any children? If so, what are the ages and gender of the children?

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f. Psychosocial History:
I. What age was the patient when they left the parental home (if applicable)?

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II. Where is the patient currently living?

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III. Does the patient currently own their own home, live in private rented accommodation,
council housing, in someone else’s home or are they homeless?

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IV. What is the current household composition?

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V. Does the person currently have any significant financial difficulties?

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10. Forensic History:

a. Does the patient have a history of contact with the Gardaí, regardless of whether or not they
served a prison sentence?

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b. Has the patient ever appeared in court? If so, for what charges and what was the outcome
(e.g. bail, prison sentence, suspended sentence, charges dropped)?

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 c. How many times has the patient been in prison (either on remand or sentenced)?

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d. What was the longest and shortest prison sentence that the patient has served?

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e. When was the patient most recently in prison and what were the charges?

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f. Does the patient have any charges pending?

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11. Premorbid Personality:

a. This is the person’s personality before they became ill and is NOT their current personality.
The premorbid personality should be recorded in the patient’s own words, using quotation
marks.

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12. Social Stressors/Support System:

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13. Physical Examination (Vitals [Blood Pressure, Respiratory Rate and Pulse Rate], Blood Glucose,
Weight, Height and BMI, CVS, Respiratory, Neurology and GI System):

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14. Mental State Examination (MSE):

a) General Appearance and Behaviour:

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b) Speech:

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c) Mood and Effect:

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d) Thought:

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e) Perception:

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f) Cognition:

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g) Insight:
I. Does the patient believe he is suffering from a mental illness?
II. Does the patient believe he needs treatment?
III. Does the patient believe that he needs to be in hospital?

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