Taking psychiatric history
Presenting complaint
- Reason for presentation (i.e. symptoms etc)
- Onset and duration of symptoms
- Method of referral
- Circumstances of the presentation
- Significant events and stressors (triggers)
- Perception of need
- Specific questions to determine DSM-IV criteria
Current mental status
i.e. Mental status examination. Ask about:
- Mood
* Hopelessness, helplessness, worthlessness
- Risk assessment
* Previous history
* Current ideation
* Plan
* Intent
- Thought possession (thought broadcast/insertion)
- Thought content (delusions)
- Perception (hallucinations)
- Cognition (MMSE)
- Judgment
- Insight
Past history
- Other psychiatric conditions (Background/Predisposing factors)
- Medical conditions
Medication history
- Medications
- Illicit drugs
- Alcohol, smoking
- Compliance and withdrawal
Family history
- Family psychiatric and medical history
Social history
- Social support
- Interaction between family members
- Functional impairment
Forensic history, Developmental history
Physical examination
- Consider neurological examination