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- 1. Name, age
- - status Mental Health Act
- - marital status, employment status, housing status
- 2. Referred
- - by who, why
- - when admitted
Record briefly each problem
- 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?
Screen for any other problems
- - low mood
- - changes in energy
- - hallucinations
- - delusional or obsessional thoughts
- - unusual experiences
- - change in social contact
- - sleep problems
- - anxiety
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
- - 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
- - what? how often? why?
- - drug allergies?
- - geneogram: for each, age, (or age at death), health, employment, relationship with pt
- - any psy history
- - any alcoholic?
- 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
- - Alcohol
- - Smoking
- - Recreational drugs: TRAP, quantity, pattern of use, effects
- - Housing
- - Support network: social support (social and informal helping networks)
- * Daily activities
- - Finances
- - all offences whether convicted or not - esp violent, sexual crimes, persistent offending
- - any charges, convictions, arrests
- - pending cases
- - Attitudes to others: in family, in social and sexual relationships
- - Attitudes to self
- - Predominant mood
- - leisure activities and interests
- - Reaction pattern to stress