Outline of history taking in Psychiatry

1. Outlines of history taking in Psychiatry
Dr. Sujit Kumar Kar
Assistant Professor in
Psychiatry
King George’s Medical
University
Lucknow, U.P

2. Socio-demographic details
• Name
• Age
• Gender
• Education
• Occupation
• Income (Monthly)
• Marital status
• Religion
• Domicile
• Type of family
• Address for correspondence –
• Contact number -

3. • Marks of identification-
• Informant –
– Reliability of the informant –
[Concern, Coherency, Consistency, Staying with,
Good observant]

4. • Chief complaints:
– 1)
– 2)
– 3)
– 4)
– Onset
– Course
– Duration
– Episode
– Precipitating factor
– Treatment taken

5. History of present illness
– Symptom analysis
• Nature
• Duration
• Severity
• Associated features
• Precipitating, perpetuating, predisposing and protective
factors
• Pervasiveness
• Impairment
– Negative history, drug history
– Vegetative symptoms

6. • History of past illness (Psychiatric illness,
Substance abuse, Medical & Surgical illness)

7. Family history
• Family dynamics
• Family history of
– Psychiatric illness
– Medical illness
– Missing person
– Suicide

8. Personal history
• Antenatal – Natal – Post Natal
• Infancy- Childhood- Adolescence
• Education
• Menstruation (females)
• Occupational history
• Marital history
• Sexual history
• Substance use

9. Pre-morbid functioning and
development
• Social relationship
• Intellectual activities, hobbies and interest
• Mood
• Character
Attitude towards work and responsibility
Interpersonal relationship
Standard in moral ,religious, social and health matter
Energy and initiative
• Fantasy life
• Habits

10. Physical examination:
o Pulse rate -
o Blood pressure -
o Temperature -
o Hydration -
o Pallor, Icterus, Cyanosis, Clubbing, Edema, Lymphadenopathy, Thyromegaly –
(specify, if any)
Systemic examination –
o Cardiovascular system –
o Respiratory system –
o Per abdominal –
o Nervous system

11. 1. General appearance and behaviour
2. Motor activity
3. Speech
4. Affect
5. Thinking
6. Perception
7. Cognition
a) Alertness
b) Consciousness
c) Orientation
d) Concentration
e) Memory
 Immediate
 Recent
 Remote
8. Intelligence
a) General fund of knowledge
b) Arithmetic ability
c) Abstract thinking
9. Judgement
10.Insight