Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Chief Complaint
Reason patient gives for presenting for treatment at this time; usually a direct quotation.
Example:
"I'm depressed."
Present Illness
Recent psychiatric symptoms (pertinent positives and negatives).
Example:
If depressed, report all SIGECAPS.
Example:
MDD: SIGECAPS
Mania: DIGFAST
Psychotic symptoms, always screen for:
o Hallucinations: do you hear things that others don't hear?
o Paranoia: do you feel safe here? How about at home? Is anyone bothering you or trying
to harm you?
If indicated, also screen for:
o Grandiosity: do you have any special powers or abilities?
o Referential thinking: do you ever feel like the TV or radio or newspapers are referring
directly to you?
o Thought broadcasting: do you ever feel that others can hear your thoughts or that others
are stealing your thoughts?
GAD: do you worry excessively? Often feel your worry is out of control? Muscle tension?
Irritability? Fatigue? Poor concentration? Restless?
Panic: attacks out of the blue? How long do they last?
OCD: anything you feel that you must do over and over again? What happens if you don't do it?
How much time do you spend? Does it interfere?
Family History
Any psychiatric illness in family?
Any substances abuse in family?
Any suicide in family?
Example:
Be flexible. If patient needs to be drawn out more and if time allows, begin this section with an open-
ended question like, "Tell me what it was like for you growing up." If patient is hyperverbal and/or
tangential, begin with closed-ended questions.
Sexual History
Sexually active currently?
When last?
Any problems?
Contraception?
Any chance of pregnancy?
Medical/Surgical History
Significant medical illnesses, medical hospitalizations, surgeries, seizures, head injuries with
loss of consciousness