Clinical History Taking Flashcards
What are the 9 areas of History Taking?
- Presenting Problem 2. Family & Developmental History 3. Educational 4. Occupational 5. Health & treatment 6. Relationship history 7. Social 8. Substance use history 9. Forensic
Why ask about history?
Because it give you a good idea of what the problems are, were they may have come from and what you may be needing to deal with in treatment and to help develop a treatment plan
Presenting Problem Questions
- “What brings you here today?” (why now) 2. “How would you describe your mood?” Symptoms – frequency, intensity, How does it start/stop, continuity? 3. When did it first begin? 4. How long have they (symptoms) been experienced? 5. Triggers? – When & where does it occur [now]? 6. Impact on client’s behaviour/life 7. How have you been managing/coping? 8. If you really want to impress in the video – think about the CBT model, and how to elicit the components that contribute
Family & Developmental History Question
- May I ask you a few questions about your childhood? 2. Where were you born? 3. Where did you grow up? 4. Did you have any serious illnesses as a young child? 5. As far as you know, did you walk and talk at the appropriate age? 6. Do you remember any significant events between the age of: 0-6?; 7-12?; 13-18?
Family & Developmental History
Are your parents still alive? Mother…father….separately? Are they in good health? Or do you mind if I ask how he/she/they died? How old are your parents? Do your parents still work? (What sort of work do/did they do?) Do you have any brothers or sisters? How old are your brothers and sisters? Are they in good health? What is your relationship with your brother/sister/parents? Supportive, poor, estranged. As far as you know, has anyone in your family had problems with their mental health? Can you tell me a little about that and how it affected their lives/you?
Educational History Questions
Where did you go to primary school/high school? What were your grades like at school? Did you enjoy school? Did you have many friends at school? Were you ever in trouble at school?; expelled or suspended? What is the highest grade you completed? Did you do any further study (e.g., University) or training (e.g., apprenticeship) when you finished school? What/Where Did you enjoy it? How successful do you believe you were at it?
Occupational History Questions
What sort of work do you do now? Where do you work? How long have you been there? Are you enjoying it? What did you do prior to that…for how long…then what happened?
Health, Medical and Treatment History
Do you have any problems with your physical health? How long have you had that problem? What sort of treatment are you on for that problem? Do you find that treatment beneficial? When is your next review for that problem?
Medication Questions
Do you take any medications regularly? What medications do you take? Inc. dosage How long have you been taking those? Their perceived effectiveness What medications have you taken previously? Do you have any allergies?
Previous Psychological Treatment
Have you had problems with your mental health previously? Have you ever seen a psychologist, psychiatrist or counsellor? How long ago? How often did you see that person? How many times did you see them? What was your concern at that time? How were you assisted with those concerns? Do you believe that assistance/approach was beneficial?
Relationship History
Are you married/in a relationship? How long How would you describe your marriage/relationship? Do you have any children? How old are they? How would you describe your relationship with your children? Who lives at home with you at the moment?
Social History
Are you married/in a relationship? How long How would you describe your marriage/relationship? Do you have any children? How old are they? How would you describe your relationship with your children? Who lives at home with you at the moment?
Substance Use History
Do you smoke cigarettes? How many? When did you begin? Do you drink alcohol? How often? How much? When begun? Have you been drinking any more or any less than normal recently? When did you last have any alcohol? Have you had any period when you didn’t drink at all? When was that? What is the longest time you have gone without having anything to drink? Have you ever used drugs? Cannabis/THC; Amphetamines (speed, ice); Opioids (heroin, methadone, morphine); Designer (ecstacy, MDA, MDMA); Benzodiazepines (diazepam, temazepam); Inhalants (glue, petrol, paint); Other (pain killers, over the counter) What sort of drugs have you used? How often? When begun? Do you continue to use any drugs? When did you last use? Withdrawal symptoms (Nicotine, Alcohol, Illicit Substances)? Consider need to explore medication misuse (if indicated)
Forensic & Risk Assessment
Personal: Forensic history Have you ever been in trouble with the police? Have you ever been convicted of anything? Risk Assessment: Violence/ Aggression Are you currently having thoughts of harming others? Have you made any threats or acted aggressively towards others? Do you have access to any weapons (inc. firearms)? Do you hear voices telling you to harm others? (command hallucinations) Do you have any history of physical/sexual & financial abuse towards others.
