History + intake

Question 1

What is taken in under identifying information

Answer 1

Name
Age
Marital status
Ethnicity
Gender
Occupation
Language

Question 2

Presenting problem

Answer 2

Why the client came to consult you
In client’s own words
If information does not come from client, note the referral and information source

Question 3

History of presenting problem

Answer 3

Chronology of emergence of symptoms
Life circumstances at time of onset
How symptoms have affected life activities and personal relations

Question 4

Past medical history?

Answer 4

Emotional / mental disturbances
Psychosomatic disorders
Medical conditions
Neurological disorders

Question 5

Family history

Answer 5

Different households lived in
Current living arrangements
Relationships with family members
Family history of medical and mental illness
Care of dependents

Question 6

Family history

Answer 6

Different households lived in
Current living arrangements
Relationships with family members
Family history of medical and mental illness
Care of dependents

Question 7

What are the four categories of personal development history

Answer 7

1. Early childhood
2. Middle childhood
3. Puberty through adolescence
4. Adulthood

Question 8

EARLY CHILDHOOD (BIRTH – 3 YRS) history

Answer 8

Prenatal Hx, pregnancy, delivery
Feeding habits
Toilet training
Symptoms of behavioural
problems
Personality and temperament
Key milestones, e.g. crawling, talking, walking

Question 9

MIDDLE CHILDHOOD (3 –11 YRS) history

Answer 9

Early school history – feelings and adjustment
Conscience, sex identification, peer rel’s, punishment, attitudes toward siblings and peers

Question 10

MIDDLE CHILDHOOD (3 –11 YRS) history

Answer 10

Early school history – feelings and adjustment
Conscience, sex identification, peer rel’s, punishment, attitudes toward siblings and peers

Question 11

Puberty through adolescence

Answer 11

Peer relationships
School
Cognitive and motor development
Particular physical or emotional problems
Psychosexual Hx: early knowledge, feelings about puberty, sexual activity and practices, attitudes toward same and opposite sex

Question 12

Adulthood

Answer 12

Occupational Hx
Education
Social activity
Adult sexuality:
Premarital relations, first sexual experience, sexual orientation
Marital history
Sexual symptoms
Sexual practices
Military history
Forensic / criminal history
Value systems: children, work, religion, afterlife
Medications used
Illicit substance(s) used
Alcohol use