 Introduce yourself

 Confidentiality discussion
 Everything we talk about is just between you and I and treatment team unless there is a risk
of harming yourself or someone else
 Especially suicide risk and harm to children under 16
 ID
 Age, gender, name (how they want to be referred to)
 How do you spend most of your time?
 What do you do for a living?
 For vocation/grade how do you financially support yourself?
 Non-judgemental way of asking about occupation
 Relationship status/who lives at home
 Chief Complaint
 What brings you in today?
 HPI
 Onset
 Precipitating factors
 Duration
 Frequency
 Severity/Intensity
 KEY: detailed description of chief complaint
 Then, associated symptoms based on DDx/ROS
 Review of Symptoms (different for Psych than standard history) – MAPS
 Mood: depression (SIGECAPS), mania (GST PAID)
 If CC not related, can ask one or two as a screening
 What do you do for enjoyment? Are you still participating in those?
 How’s your appetite and sleep? How’s your mood?
 Have you done anything lately out of character?
 Grandiose delusions – have you ever felt on top of the world? Do you have any
special powers or abilities that other people don’t have?
 Sleep – decreased need for sleep – have there even been a time where you
haven’t needed a lot of sleep but have lots of energy?
 Talkative – non-interruptible
 Pressure of speech
 Activity – increase in risky active – spending, promiscuity
 Ideas – flight of ideas
 Distractibility
 Anxiety disorders: generalized anxiety disorders, OCD, social anxiety disorders, panic
disorders, PTSD
 How to screen for GAD: Do you worry a lot about day to day things? Do your consider
yourself a worrier?
 How to screen for OCD: Do you find that you have thoughts that you can’t get out of
your head? Do you have any rituals or behaviours that you feel you have to do or
interfere with daily life?
 How to screen for panic: Do you ever have anxiety or panic attacks?
 How to screen for PTSD: Do you ever have flashbacks? What’s the worst thing that’s
ever happened to you? How does that affect you now?
 Psychosis disorders: hallucinations and delusions
  Psychosis: detached from reality
 Delusions: Are you worried that someone’s out to get you?
 Hallucinations: Is there anything you hear or see that you think other people don’t see
or hear?
 Suicide and substance
 Do you have suicidal thoughts?
 Do you have a plan?
 Have you ever acted on it? Do you think you’ll act on it?
 How many drinks do you have a week?
 How much do you smoke a day?
 What else do you use?
 OTC, recreational drugs
 Past Psych History
 Have you ever been hospitalized?
 Previous diagnoses
 Past medications prescribed/trials and response
 Suicide attempts
 PMHx
 Previous hx of head trauma or seizures**
 Have you hurt your head/knocked unconscious?
 Seizures/epilepsy
 Meds
 Doses
 Adverse reactions
 Recent changes
 OTC and herbal meds
 Allergies
 Fam Hx
 Is there any history of mental illness in their family?
 List disorders specifically including substance use
 Has anyone ever completed suicide?
 Social Hx
 Legal history
 Ask about trauma – hurt physically/sexually/emotionally? If yes which one? How does that
affect you know?
 Don’t need to know tons of details?
 Education
 Job history
 Romantic history
 Religion/spiritual
 Assess functioning
 IADL’s
 Shopping
 Housekeeping and hobbies
 Accounting
 Food preparation
 Transportation
 ADL’s:
  Dressing
 Eating
 Ambulation
 Toileting
 Hygiene
 If over 65, automatically do a MoCA/MMSE
 Substances
 Developmental Hx/Trauma Hx
 Prenatal hx – substance/stress exposure in utero
 Developmental milestones
 What were things like growing up?
 Things up when you were at home?
 Relationships with parents
 How was school as a kid?
 Relationship with peers
 Bullying
 Academic performance