The document provides a detailed structure for history taking in psychiatric evaluations, emphasizing the importance of understanding the patient's life, including their identity, past medical history, and current complaints. It outlines a comprehensive format for gathering information, including the chief complaint, treatment history, family background, personal history, and premorbid personality. Ultimately, this historical data is crucial for clinicians, particularly psychiatrists, to formulate a complete psychiatric assessment.

1. Topic -HISTORY TAKING

3. HISTORY TAKING
INTRODUCTION
 IT IS THE RECORD OF THE PATIENTS LIFE
 IT ALLOWS TO UNDERSTAND
1. Who the patient is.
2. Where the patient has come from.
3. Where the patient is likely to go in the future

4. HISTORY TAKING FORMAT
IDENTIFICATION DATA
NAME – AGE/SEX –
FATHER/SPOUSE –
ADDRESS –
EDUCATION –
OCCUPATION –
INCOME –
MARITAL STATUS –
RELIGION –
INFORMANT -

5. 1. CHIEF COMPLAINT
( With duration In Chronological Order, In Patients Own Words And
Informants Own Words )
2. HISTORY OF PRESENT ILLNESS
DURATION (days/weeks/months/years) :
MODE OF ONSET : Abrupt| Acute | Insidious (<48hours|<1week|1-2 weeks within a few
weeks)
COURSE : Continuous |Episodic |Fluctuating |Improving | Unclear
INTENSITY : Same | Increasing| Decreasing
PRECIPITATING FACTORS : Yes/No, if yes explain

6. 3. TREATMENT HISTORY
DRUGS(name of the drug ,dose ,route , side-effects, if any) :
ECT :
PSYCHOTHERAPY :
FAMILY THERAPY :
REHABILITATION :
4. PAST PSYCHIATRIC AND MEDICAL
HISTORY
NUMBER OF PREVIOUS
EPISODES|HOSPITALIZATION(Psychiatric) WITH
ONSET AND COURSE :
COMPLETE OR INCOMPLETE REMISSION :
DURATION OF EACH EPISODES :
TREATMENT DETAILS AND ITS SIDE EFFECTS IF ANY :
TREATMENT OUTCOME :
DETAILS OF ANY PRECIPITATING FACTORS IF PRESENT:
SUBSTANCE USE DETAILS :

7. 5. FAMILY HISTORY
DESCRIPTION (describe each family member briefly ) : Age, Education,
Occupation, Health Status, Relationship with the patient, Age at death,
Mode of death
6. PERSONAL HISTORY
A. PERINATAL HISTORY
ANTENATAL PERIOD : Maternal Infections |Exposure To Radiation|
Any Other Check Ups
INTRANATAL PERIOD : Type of delivery- normal| Instrumental|
Cesearian Any Complications
BIRTH : Full Term |Premature |Postmature
BIRTH : Immediate |Delayed
BIRTH DEFECTS : Yes or No, if yes, specify
POSTNATAL COMPLICATION : Cyanosis | Jaundice | Neonatal Infection |
Any Other

8. B. CHILDHOOD HISTORY
PRIMARY CAREGIVER :
FEEDING : Breastfeed| Artificial Mode Of Feeding
AGE AT WEANING :
DEVELOPMENTAL MILESTONES : Normal | Delayed
BEHAVIOUR AND EMOTIONAL PROBLEMS : Thumb Sucking| Stuttering| Head-
Banging|
Body Rocking| Nail biting| Morbid Fears
ILNESS DURING CHILDHOOD : Specifially For CNS Infections| Epilepsy|Neurotic
Disorders|Malnutrition
C. EDUCATIONAL HISTORY
AGE AT BEGINNING OF FORMAL EDUCATION :
ACADEMIC PERFORMANCE :
EXTRACURRICULAR ACHIEVEMENTS,

9. RELATIONSHIPS WITH PEERS AND TEACHERS :
SCHOOL PHOBIA :
LOOK FOR CONDUCT DISORDERS,For Example Truancy|Stealing :
Yes|No
REASON FOR TERMINATION OF STUDIES :
D. PLAY HISTORY
GAMES PLAYED ( at what stage and with whom) :
RELATIONSHIP WITH PLAYMATES :
E. EMOTIONAL PROBLEMS DURING
ADOLESCENCE
Running Away From Home| Delinquency| Smoking| Drug-Taking|Any
other (specify)

10. F. PUBERTY
AGE AT APPEARANCE OF SECONDARY SEXUAL CHARACTERISTICS :
ANXIETY RELATED TO PUBERTY CHANGES :
AGE AT MENARCHE :
REGULARITY OF CYCLES, DURATION OF FLOW :
ABNORMALITIES, If Any ( Menorrhagia, Dysmenorrhea) :
G. OBSTETRICAL HISTORY
LMP :
NUMBER OF CHILDREN :
ANY ABNORMALITIES ASSOCIATED WITH PREGNANCY, DELIVERY :
TERMINATION OF PREGNANCY, If Any :
MENOPAUSE :

11. H. OCCUPATIONAL HISTORY
AGE AT STARTING WORK :
JOBS HELD IN CHRONOLOGICAL ORDER :
REASON FOR CHANGES :
CURRENT JOB SATISFACTION :
I. SEXUAL AND MARTIAL HISTORY
GENOGRAM :
TYPE OF MARRIAGE : Self – choice | Arranged
DURATION OF MARRIAGE :
INTERPERSONAL AND SEXUAL RELATIONS : Satisfactory | Unsatisfactory
EXTRAMARTIAL RELATIONSHIP, If Any Specify :

12. J. PREMORBID PERSONALITY
INTERPERSONAL RELATIONSHIPS :
FAMILY AND SOCIAL RELATIONSHIPS :
USE OF LEISURE TIME :
PREDOMINANT MOOD :
USUAL REACTION TO STRESSFUL EVENTS :
ATTITUDE TO SELF AND OTHERS :
ATTITUDE TO WORK AND RESPONSIBILITY :
RELIGIOUS BELIEFS AND MORAL ATTITUDES :
FANTASY LIFE :
HABITS
EATING PATTERN :
ELIMINATION :
SLEEP :
USE OF DRUGS, TOBACCO, ALCOHOL :

13. SUMMARY
 The History and information of the patient is collected and the clinician usually then
considers any other factors that might be relevant to the particular patient and
enquires
about them. Although the gathering of the information may follow the flow of the
patients
thoughts rather than those of the clinician , it is not uncommon for the clinician to
record
the psychiatric history under headings to make it easier for others who will later read
it.
 Subsequent history taking concentrates on changes in the levels of symptoms and
responses
to treatment , including possible side efffects

14. CONCLUSIONS
 A Psychiatric history taking is the result of a medical process
where a clinician working in the field of mental health (usually a
psychiatrist) systematically records the content of an interview
with a patient. This is then combined with the mental status
examination to produce a “PSYCHIATRIC FORMULATION” of
the person being examined