Pyschiatry history checklist

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Author:
trincam2008
ID:
275013
Filename:
Pyschiatry history checklist
Updated:
2014-05-21 16:12:46
Tags:
Psy historytaking
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Description:
Psychiatry history taking
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  1. Patient details
    • 1. Name, age
    • - status Mental Health Act
    • - marital status, employment status, housing status

    • 2. Referred
    • - by who, why
    • - when admitted
  2. Presenting complaints
    Record briefly each problem
  3. HPC
    • For each problem
    • - when did it start? (S)
    • - how did it develop? (C)
    • - associated symptoms? (A)
    • - any precipitating event? (T)
    • - how does it affect day-day function?
    • - associated symptoms? (E)
    • - what helps and what makes it worse? (E)
    • - has the pt sought help?
  4. Screen for any other problems
    • - low mood
    • - changes in energy

    • - hallucinations 
    • - delusional or obsessional thoughts
    • - unusual experiences

    • - change in social contact
    • - sleep problems
    • - anxiety
  5. Past Psy hx
    • - any previous problem? - treated or untreated?
    • - any hospitalisation? for how long?
    • (if complex, no of admissions, when first began, details of last 3 or 4)
    • - detention under MHA?
    • - previous diagnoses? any self harm?
    • - any treatment? what was the response?
    • (including psychological treatments and counselling as well as drugs, depot medication and courses of ECT)
    • - state of health and level of functioning between episodes
  6. PMH
    • - chronological order
    • - major illnesses, accidents or operations 
    • - ask esp for epilepsy, head injuries, stroke, heart diseases, chronic illness

    • - HTN, diabetes, jaundice, e.g. as a result of hepatitis
    • - screen for current physical symptomatology e.g breathlessness, constipation, dizziness
  7. DHx
    • - what? how often? why?
    • - drug allergies?
  8. FHx
    • - geneogram: for each, age, (or age at death), health, employment, relationship with pt
    • - any psy history
    • - any alcoholic?
  9. Personal hx
    • 1. Childhood
    • - which area pt was born?
    • - problems around birth?
    • - development milestones?
    • - childhood memories of family?
    • - any abuse?

    • 2. School
    • - what age, which school
    • - when left school
    • - relationship with teachers and peers, inc bullying
    • - school refusal/truancy
    • - training and qualifications

    • 3. Occupation
    • - job taken, for how long, why left
    • - how long unemployed/retired

    • 4. Relationships
    • - current and past
    • - how long, why ended/widowed
    • - children

    • 5. Sexual history
    • - puberty
    • - sexual orientation
    • - first sexual orientation
    • - sexual difficulties
  10. SHx
    • - Alcohol
    • - Smoking
    • - Recreational drugs: TRAP, quantity, pattern of use, effects
    • - Housing
    • - Support network: social support (social and informal helping networks)
    • * Daily activities
    • - Finances
  11. Forensic hx
    • - all offences whether convicted or not - esp violent, sexual crimes, persistent offending
    • - any charges, convictions, arrests
    • - pending cases
  12. Personality
    • - Attitudes to others: in family, in social and sexual relationships
    • - Attitudes to self
    • - Predominant mood
    • - leisure activities and interests
    • - Reaction pattern to stress

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