Presenting Complaint

• Patient’s name
• Age
• Demographic information
• Reason for presentation
• If referred in, by whom?

History of presenting Complaint

• This is an account of the patient’s history in their own words.
• Explore thoroughly what they presented with, for example, low mood, hearing voices, etc.
• Screen for other symptoms – mood, psychosis, anxiety
• Always think about risk – to health, safety or welfare to self or others

Psychiatric history

• Diagnosis
• When first referred to psychiatry
• Treatment by GP for mental illness
• Current input
  • attends outpatient clinic?
  • CPN?
  • psychology?
  • occupational therapy?
  • 3^rd sector support? (eg. support worker, or other support from a charity)
• Previous treatments, dates given, and what was helpful
• Previous hospital admission
• Previous/current detentions under the Mental Health Act
• Previous episodes self harm

Medical history

• Any significant past or current medical history

Medication history

• Current medication
• Compliance
• Side effects
• Over the counter medication
• Allergies

If appropriate, then past medication history

If the patient is prescribed a depot medication:

• When was it last given? 
• When is next dose due?
• Where do they get their depot +/- who administers this? 

If you see something about a T2b or a T3b form in a patient's notes, please discuss with your local psychiatry department before commencing any new psychiatric medication for the patient (unless it is not practicable to do so in an emergency situation). There are restrictions around prescribing psychiatric medications for these patients related to their detention under the mental health act. 

Family history

• First ask a broad question to establish if anyone in the patient’s family has suffered from mental illness.
• In cases of adoption or step-parents note information regarding biological and social family.
• For all first degree relatives – mother, father, siblings, children – age, age of death (if deceased) and cause of death, history of mental illness, history of physical illness, occupation, quality of relationship with patient in childhood and thereafter

Social history

• Housing – type of accommodation, any issues
• Employment, source of income
• Money worries – debt, money lenders, catalogues, loan sharks, gambling problems, etc.
• Smoking
• Alcohol – amount, features of harmful use or dependency
• Drugs – what substances used, amount, features of dependency

 Personal history

Please note that there is no need to go into details about previous traumas if that information is already known. There is a risk of re-traumatising the patient. It is enough to say ‘we are aware that X was a difficult time in your life – I don’t need to know any more just now unless you think it affects what we plan today’ or similar.

• History of birth trauma, place of birth
• Family circumstances in childhood
• Early (pre-school) childhood – developmental difficulties, bedwetting, temper tantrums,
• History of physical or sexual abuse 
• Primary school – educational achievement, enjoyed/didn’t enjoy, friends, bullying, trouble, suspension, expulsion, truancy
• Secondary school - educational achievement, enjoyed/didn’t enjoy, friends, bullying, trouble, suspension, expulsion, truancy, qualifications achieved, age of leaving school
• Further education - qualifications
• Employment history – chronological list of jobs, how they were, relationships with colleagues, why they ended
• Current employment – how is it
• Relationships – past and present significant, how long did they last, how were they, why did they end
• Friendships – supportive, confiding?
• Hobbies/interests
• Religion

 Forensic history

• Past and pending charges
• Previous convictions
• Previous imprisonment
• History of physical aggression, even if not charged

Premorbid personality

• Ask the patient to describe what they were like before they were ill
• How would their friends describe them
• Relationships – shy or makes friends easily, lasting or superficial friendships, few or many
• Prevailing mood – generally cheerful or gloomy, changes in mood
• Hobbies and interests
• How would they usually respond to stress