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Psychiatric History Cheat Sheet (DRAFT) by

Psychiatric history taking cheat sheet

This is a draft cheat sheet. It is a work in progress and is not finished yet.

1. Opening the Consul­tation

Wash your hands Introduce yourself (full name) and role
Confirm patient's name and date of birth
Establish confid­­en­t­i­ality
Confid­­en­t­i­ality: "­­An­y­thing said here today will be confid­­ential unless I feel another person or yourself is at immediate risk, in which case I would need to share some inform­­ation. I appreciate some questions may be difficult to answer, if there is anything you don't want to answer right now, we can come back to it another time. Does that sound okay?"

2. Exploring PC

NOTEPAD

Nature
Onset
Triggers
Exacer­bat­ing­/re­lieving factors
Progre­ssion
Associated symptoms
Disability

2.1 Hx of PC - Low Mood

How has your mood been recently?
Have you felt low in yourself?
Have you felt little interest or pleasure in doing things?
Have your energy levels been lower than normal?
Associated symptoms to ask about

Disturbed sleep
Change in appeti­te/­weight
Agitation or slowing down of movements and thoughts
Poor concen­tration
Thoughts of self-h­arm­/de­ath­/su­icide

2.2 Hx of PC - Hypoma­nia­/mania

"Have you noticed any change in your mood or energy levels recent­ly?­"
"Can you describe the change­?"
Have you felt more irritable or impatient than usual?­"
Associated Symptoms

Increased self-e­steem
Reduced social inhibi­tions
Over-f­ami­liarity
Reduced attention
Inappr­opriate sexual encounters
Self-n­eglect

2.3 Hx of PC - Anxiety

"Have you been worrying a lot about things recent­ly?­"
"Are you always anxious or does it happen at certain times?­"
"Do you avoid doing things because of your worrie­s?"
Associated physical symptoms

Palpit­ations
Chest tightness
Breath­les­sness
Sweating
Dizziness
Dry mouth
Nausea and committing
Insomn­ia/­dif­ficult sleeping

Important to screen for co-exi­sting depression in patients

2.4 Hx of PC - Psychosis

Halluc­ina­tions
Do you ever hear noises or voices when there is nobody else there?
 
Do you feel that someone or something is touching you when there is nobody there?
Delusions
Do you sometimes have thoughts that others tell you are false?
 
Is there anyone­/an­ything putting thoughts into your head that you know are not your own?
 
Is there anyone or anything taking thoughts out of your head?
 
Are your thoughts your own?
 
Can anyone hear your thoughts? For example, can I hear what you are thinking right now?
 

2.5 Hx of PC - Obsessions and Compul­sions

Do you get repeated unpleasant thoughts or images coming into your mind?
Do you get these thoughts entering your mind despite trying to keep them out?
Do you ever feel that you need to repeatedly check things that you have already done?

2.6 Hx of PC - Alcohol or substance abuse

Alcohol (CAGE)
Have you ever felt you ought to Cut down on your drinking?
 
Have people Annoyed you by critic­ising your drinking?
 
Have you ever felt Guilty about drinking?
 
Have you ever felt you needed a drink first thing in the morning (Eye-o­pener) to steady your nerves or get rid of a hangover?
Drugs
Amount of money spent?
 
Route of admini­str­ation
General
Have you ever experi­enced withdrawal symptoms?
 
Has the use caused any physical or mental health problems =?
 
Have you continued to use, even though you knew you had problems?

2.7 Hx of PC - Eating disorders

Building a picture
Can you describe a typical day's food intake?
 
How often do you weight yourself?
 
What has your weight been like in the past?
Adaptive behaviours
Exercise
 
Purging
 
Binge eating
Additional physical symptoms

Amenor­rhoea
Fatigue
Consti­pation
Dizziness
Haemat­emesis
Seizures

3. ICE + Summar­ising

Ideas
Concerns
Expect­ations
Summar­ising

4. Past Psychi­atric History

Existing diagnosis
New condition, or a relapse?
Previous treatment
Clarify effect­iveness
Past contact with mental health services
Primary care? Community mental health team? Crisis team?
 
Hospital admission: number of admission, informal or under section of MHA? Admitted to PICU?

5. Forensic history

Have you ever had any contact with the police?
If yes, what happened? Were you charged?
Have you spent any time in prison?
 

6. Past medical history

Are there any medical conditions you are currently seeing your GP for?
Any recent surgeries?
Any recent hospital admiss­ions?

7. Drug history

Any prescr­iptive medica­tions? Herbal remedies? Over-t­he-­cou­nter?
Recent medication changes?

8. Family history

Have any of your parents or siblings had problems with their mental health in the past?

9. Personal history

Childhood
Do you know if there were any problems during your mother's pregnancy with you?
 
How would you describe your childhood?
School and education
Did you enjoy school?
 
At what age did you leave school?
Occupation
Are you employed at the moment?
 
How long have you been at your current job?
Relati­onships
How do you get on with your family?
 
Do you feel like you have a good social support system?
 
Have your current problems affected your relati­onship?
 
What have your romantic relati­onships been like?
Pre-morbid person­ality
How would you describe yourself?
 
How would others describe you?

10. Social history

Living circum­stances
Ask about living situation
 
Ask about children at home - safegu­arding
Activities of daily living
Diet, financial concerns, housework
Smoking
Type and amount of tobacco used
Alcohol
Frequency, type and volume of alcohol
Drugs

11. Insight

What do you think the cause of the problem is?
Do you think you have a problem at the moment?
Do you feel you need help with your problem
Patient's ability to understand that they have a mental health problem and that what they're experi­encing is abnormal.