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Psychiatric History:: Personal Data

This document contains sections for collecting a patient's psychiatric history including identification data, chief complaint, history of present illness, past psychiatric history, medical history, family history, personal and social history, substance use, legal issues, and personality traits. It includes fields for personal information like name, age, gender, address, occupation, education, and more. The chief complaint section asks about the nature, onset, course, severity and duration of the issue as well as its effects. The history of present illness chronologically outlines the problem and any relevant issues, symptoms, treatments, and important factors. Other sections address past medical/psychiatric illnesses, family mental health history, the patient's personal history and premorbid personality.

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wafaa alwafi
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2K views5 pages

Psychiatric History:: Personal Data

This document contains sections for collecting a patient's psychiatric history including identification data, chief complaint, history of present illness, past psychiatric history, medical history, family history, personal and social history, substance use, legal issues, and personality traits. It includes fields for personal information like name, age, gender, address, occupation, education, and more. The chief complaint section asks about the nature, onset, course, severity and duration of the issue as well as its effects. The history of present illness chronologically outlines the problem and any relevant issues, symptoms, treatments, and important factors. Other sections address past medical/psychiatric illnesses, family mental health history, the patient's personal history and premorbid personality.

Uploaded by

wafaa alwafi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Psychiatric history:

 Identification data.
 Referral Source.
 Chief Complaint.
 History of present illness.
 Past Psychiatric history.
 Medical history.
 Family history.
 Personal and Social history.
 Tobacco and substance abuse.
 Legal (forensic) problems.
 Personality traits.

Personal data
 Name:
 Age:
 gender:
 Marital status:
 Religious:
 Address:
 Occupation:
 Education
 Nationality
 Referred by: Brief statement of how the patient came to the clinic
and the expectations of the consultation.
 Informant

Chief Complaint:
Nature,
Onset,
Course,
Severity,
Duration
Effects on the patient (social life, job, family…)

History of Present Illness:


 Chronological background of the psychiatric
problem: Nature, Onset, Course, Severity,
Duration, Effects on the patient (social life, job,
family…)
 Review of the relevant problems.
 Symptoms not mentioned by the patient (e.g.
Sleep, appetite, …)
 Treatment taken so far (nature and effect).
 Important –Ve (e.g. history of mania in
depressed patient )
Suicide ,homicide, substance abuse, and organic disease
 Don’t forget S.O.A.P
S- suicidal & homicidal
O- organisity
A- addiction
P- psychosis

Past psychiatric illness


 Any previous psychiatric illness (nature, dates,
treatment, outcome).

Past medical history


 All major illnesses should be listed
FAMILY HISTORY:

 Ask about mental illnesses in first and second-


degree relatives (grand parents, uncles, aunts, nephews,
& nieces).
 Mother and father: current age (if died
mention age and cause of death, and patient’s age at
that time).
 Sibling (age, illness, order of Pt.)

(social position / atmosphere)


PERSONAL HISTORY

Mother’s pregnancy and the birth:………………………


Early development:( 0-3)………………………………..
Childhood:( 3-11)……………………………………….
Separations:……………………………………………..
Emotional problems:…………………………………….
Illnesses:…………………………………………………
Schooling & higher education:…………………………
………………………………………………………….
Occupational history:…………………………………
…………………………………………………………
Menstrual history:………………………………………..
……………………………………………………………
Sexual history:……………………………………………
Marital history:…………………………………………..
Children:
………………………………………………………………………………………………
……………..
Social circumstances:……………………………………
………………………………………………………….
………………………………………………………………………………………………
…………………………
:…………………………………..
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………...
Current medication:………………………………………
……………………………………………………………
Substance use:……………………………………………
………………………………………………………………………………………………
…………………………
……………………………………………………………
Forensic history:………………………………………….
……………………………………………………………
……………………………………………………………
Premorbid PERSONALITY:
Relationships:………………………………………….
……………………………………………………………
Mood:…………………………………………………..
Leisure activities:………………………………………
Character:………………………………………………
Attitudes & standards:…………………………………
Habits:………………………………………………….

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