PSYCHIATRY II

2019A
I . IDENTIFYING DATA

Name:

Age: Sex: Marital Status:

Number of Children Religion

Address

Occupation Race/Ethnicity

Number of Admission/s (Psych

Number of Consult
cases; Indicate if same or
different)

Referral Source

Sexual Orientation

Gender

II. SOURCE AND

RELIABILITY

III. CHIEF COMPLAINT

IV. HISTORY OF PRESENT ILLNESS (Use another sheet if necessary)

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V. PAST PSYCHIATRIC

HISTORY (INCLUDE

SYMPTOMS, Dx,

Treatment, Date, Number

of episodes)

VI. SOCIAL HISTORY

Social Interactions

Hobbies and Interests

Hopes

Short-term goals
Long term goals

Aspirations

Others

Alcohol/Drugs involved

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HISTORY OF SUBSTANCE

ABUSE (Under Social

History)

Start of use

Last use

How drugs were acquired

Efforts to cut down

Effect on relationship with

others

Effect on work/roles in life

Withdrawal

Tolerance

Caffeine intake

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VII. PAST MEDICAL HISTORY

Major Illnesses (Include pediatric Treatment Coping/Recovery

developmental problems; birthing/prenatal
problems; include allergies as well)

Adverse Drug Reaction

reactions to

Drugs

(include

changes in

mood, sexual

function)

Co-morbidities (include maintenance drugs, intake schedule, and adjustment of px to condition)

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Surgeries (Include Dx, date, procedure if recalled)

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Reproductive G ___ P ___ Term ___ Premature ___ Living ___ Abortion ___

and

Menstrual
# Date of Delivery AOG (Weeks) Manner of Complications/Conditions Sex
history Delivery

(Women)

Date of Menarche:_______________________
Date of Menopause:_________________ Age of Menopause:______________
First day of last menstruation:_______________
Duration of menstrual period:__________________ Days of cycle:________
Flow:_____________________________

OTHER THERAPEUTIC/ SUPPLEMENTAL DRUGS TAKEN REGULARLY

VIII. FAMILY HISTORY (Put emphasis on Psychiatric history, substance abuse history, support system/stressors in the family; may be
visualised through a genogram; Ask to describe each family member)

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VIII. Anamnesis (Personal/Life History)

Prenatal/Natal

Early Childhood (0-3 y/o)

Middle Childhood (4-11 y/o(

Late Childhood (11-18 yo)

Adulthood

Educational Hx

Work

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Marriage and relationship/s

Age at first coitus: _____ y/o

Date of last sexual intercourse: ________________________
Sexual orientation/preference: ________________________
No. of sexual partners
in the last 6 months __________________________
in the last 5 yrs ______________________________
in the patient’s lifetime _______________________
History of sexually transmitted infections: ________________
__________________________________________________
__________________________________________________
Routine contraceptive use: Yes (please specify) _________________ No ___

Natural Method:
___ Withdrawal

Rhythm Method:
___ Calendar
___ Basal Body Temperature
___ Cervical Mucus
___ Symptothermal
___ Lactation Amenorrhea Method (LAM)
Artificial Method:
___ Chemical barriers (spermicides,
vaginal sponge)

Physical barriers:
___ Diaphragm
___ Cervical cap
___ Condom (male/female)
Sexual History ___ Oral contraceptive pills
___ Injectables
___ Subdermal implants
___ Morning-after pill
___ Contraceptive patch
___ Intrauterine device (IUD)

Permanent Method:
___ Vasectomy
___ Tubal ligation

History of sexual abuse?___________________

Details:

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Legal History

Military

Religion

Fantasies and Dreams

History of domestic

violence/abuse

Others

REMINDER: Please refer to 2nd Year Psych Trans (2.02 Hx Taking in Psychiatry) and Chapter 5 of Kaplan for specific details on Psych
History taking.

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