Click here to view next page of this article
Psychiatric History
Identifying Information. Age, sex, marital status, race, referral source.
Chief Complaint (CC). Reason for consultation; the reason is often a direct quote from the patient.
History of Present Illness (HPI)
1. Current Symptoms: Date of onset, duration and course of symptoms.
2. Previous psychiatric symptoms and treatment.
3. Recent Psychosocial Stressors: Stressful life events which may have contributed to the patient's current presentation.
4. Reason the patient is presenting now.
5. This section provides evidence that supports or rules out relevant diagnoses. Documenting the absence of pertinent symptoms is also important.
6. Historical evidence in this section should be relevant.
Past History
1. Previous and current psychiatric diagnoses evaluation.
2. History of psychiatric treatment, including outpatient and inpatient treatment.
3. History of psychotropic medication use.
4. History of suicide attempts and potential
Past Medical History
1. Current and/or previous medical problems.
2. Type of treatment, including prescription, over the counter medications, home remedies.
Family History. Relatives with history of psychiatric disorders, suicide or suicide attempts, alcohol or substance abuse.
Social History
1. Source of income.
2. Level of education, relationship history (including marriages, sexual orientation, number of children); individuals that currently live with patient.
3. Support network.
4. Current alcohol or illicit drug usage.
5. Occupational history.
Developmental History. Family structure during childhood, relationships.