History Taking

• Confidentiality:
  • “Hi, my name is Dr. Roman. I want to start by letting you know that everything we talk about will be confidential unless there’s a concern about harm to yourself or someone else.”
• Open-Ended Question:
  • “How can I help you today?”

Understanding the Chief Complaint

• Clarifying ‘Crazy’:
  • “Your parents think you’re crazy… could you please elaborate on that?”
• Timeline:
  • “How long have you been experiencing these feelings/thoughts?”
  • “Is this something that’s been going on continuously, or does it come and go?”
  • “Have things been getting better, worse, or staying about the same recently?”
• Triggers: “Is there anything that makes these feelings/thoughts worse?”
• Additional Concerns: “Are there any other problems you’re experiencing alongside this?”
• Coping: “Have you found anything that helps you manage these feelings/thoughts, or things that make them worse?”
• Impact on Life: “How are these feelings/thoughts affecting your day-to-day life?”

Psychosocial History

Psychological

• Mood Questions (MASA-OPP)

  • “How has your mood been lately? Depressed, down, happy, or something else?”
  • “Have you noticed changes in your appetite? Are you eating more or less than usual?”
  • “How’s your sleep? Any trouble falling asleep, staying asleep, or waking up too early?”
  • “Are you feeling worried or anxious about things more than usual?”
  • Obsessions/Compulsions:
    • “Do you have thoughts that you can’t get out of your head that cause you anxiety?”
    • “Do you feel like you have to do certain things repeatedly to make the anxiety go away?”
  • PTSD/Phobias: (If relevant based on presenting complaints)

• Psychosis Questions

  • Suicidal Ideation:
    • “Have you had thoughts of harming yourself or others?”
    • (If yes) “Have you ever acted on these thoughts before? What happened?”
    • (If yes) “Do you have a plan for how you would do it? Have you gathered the things you might need?”
  • Hallucinations:
    • “Do you sometimes see, hear, smell, feel, or taste things that other people don’t experience?”
  • Delusions (RCG2P2J):
    • “Do you have any beliefs or thoughts that others might find unusual or strange?” (Explore specific types if needed)

• Functioning, Insight, Cognition, Judgement:

  • “I’m going to ask a few questions that might seem odd, but they help me understand your situation better.”
  • “Do you believe you might need some help with what you’re going through?”
  • “Do you know who I am, where we are, and what the date is?”
  • “If there were a fire in this room, what would you do?”

Social History

• HEADSS
  • Home: “Tell me about your living situation. Who do you live with? Do you feel supported?”
  • Education/Employment: “How are things at school/work?”
  • Activities: “Are you still doing things you enjoy, or spending time with friends?”
  • Drugs: “Do you use any alcohol, tobacco, or other drugs? How often?” (Can be phrased more conversationally if appropriate)
  • Suicidal Ideation: (If not covered thoroughly earlier)
  • Sexual History: (If relevant – be sensitive)

Additional Notes

• Organic Causes: Ask about physical health, injuries, thyroid issues, medications, etc.
• Previous Admissions/Medications: “Have you ever been seen by a mental health professional or been on medications before? Why did you stop?”
• Past Medical History (PMH): Focus on conditions that could have mental health implications.
• Family Medical History (FMH): Any mental health conditions in the family?