THE SCHEME OF HISTORY TAKING (Gelder, Gath, Mayou, 1993)
Informant Name, relation to patient, intimacy, and length of acquaintance. Interviewer's impression of informant's reliability.
Source of referral and reasons for referral
Present illness Symptoms with duration and mode of onset of each. Description of the time relations between symptoms and physical disorders and psychological or social problems. Effects on work, social functioning, and relationships. Associated disturbance in sleep, appetite, and sexual drive. Any treatment given by other doctors.
Family history Father: age now or at death. (If dead give cause of death.) Health, occupation, personality, quality of relationship with patient. Mother: the same items. Siblings: names, ages, marital status, occupation, personality, psychiatric illness, and quality of relationship with, patient. Social position of family-atmosphere in the home.
Family history of mental illness-psychiatric disorder, personality disorder, epilepsy, alcoholism. Other neurological or relevant medical disorders (e.g. Huntington's chorea).
Personal history Early development: abnormalities during pregnancy and at birth. Difficulties in habit training and delay in achieving milestones (walking, talking, sphincter control, etc.). Separation from parents and reaction to it. Health during childhood: serious illness, especially any affecting the central nervous system, including febrile seizures. `Nervous problems' in childhood: fears, temper tantrums, shyness, stammering, blushing, food-fads, sleep-walking, prolonged bed wetting, frequent nightmares. School: age of starting and finishing each school. Types of school. Academic record. Sporting and other achievements. Relationships with teachers and pupils. Higher education: comparable enquiries. Occupations: chronological list of jobs, with reasons for changes. Present financial circumstances, satisfaction in work. Service or war experience: promotion and awards. Disciplinary problems. Service overseas.
Menstrual history: age of menarche, attitude to periods, regularity, and amount, dysmenorrhoea, premenstrual tension, age of menopause and any symptoms at the time, date of last menstrual period.
Marital history: age of patient at marriage. How long spouse known before marriage and length of engagement. Previous relationships and engagements. Present age, occupation, health, and personality of spouse. Quality of the marital relationship.
Sexual history: attitude to sex. Heterosexual and homosexual experience. Current sexual practices, contraception.
Children: names, sex, and age of children. Date of any abortions or stillbirths. Temperament, emotional development, mental and physical health of children.
Present social situation Housing, composition of household, financial problems.
Previous medical history Illness, operations, and accidents. Previous psychiatric illness Nature and duration of illness. Date, duration, and nature of any treatment. Name of hospital and of doctors. Outcome. Personality before present illness Relationships: friendships, few or many; superficial or close; with own or opposite sex. Relations with workmates and superiors. Use of leisure: hobbies and interests; membership of societies and clubs. Predominant mood: anxious, worrying, cheerful, despondent,
optimistic, pessimistic, self-depreciating, over-confident. Stable or fluctuating. Controlled or demonstrative. Character: sensitive, reserved, timid, shy; suspicious, jealous, resentful; quarrelsome, irritable, impulsive; selfish, self-centred; self-conscious, lacking in confidence; dependent; strict, fussy, rigid; meticulous, punctual, excessively tidy. Attitudes and standards: moral and religious. Attitude towards health and the body. Habits: food, alcohol, tobacco, drugs.