Taking a psychiatric history

What it is

The psychiatric history runs in a fixed order, and the order itself is part of what is asked.

1. Introduction of yourself.

1. Patients information and demographics: name, age, where he lives, if he works, marital state.

1. Referral information: coming to the hospital by referral or by his own, and whether forced or not.

1. Chief complaint.

1. History of presenting complaint.

1. Past psychiatric history.

1. Personal history.

1. Past medical.

1. Past surgical.

1. Medication.

1. Allergic history.

1. Family history.

1. Social history: income source, employment, education, support system, legal issues, married.

The five symptom groups of the presenting complaint

The history of presenting complaint has a set shape. It is taken over five named symptom groups -- psychotic, mood, somatic, behavioral and cognitive -- with risk assessment added beside them, and what belongs under each is as follows.

Psychotic symptoms: thoughts, and perception.

Mood symptoms: mood.

Somatic symptoms: sleep; appetite; sweeting; palpitation; chest pain; shortness of breath.

Behavioral symptoms: attitude; eye contact; overfamiliar, disinhibited or suspicious; any abnormal movement.

Cognitive symptoms: cognition, taken as orientation, then memory, then calculation.

Risk assessment, plus insight and judgment beside it.