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Clinical Guide

PSYCHIATRIC HISTORY TAKING MANUAL

A Global Med Tutor Clinical Guide for Medical Students and Practitioners

About This Manual

In psychiatry, the history is the main diagnostic tool. Psychiatric OSCE stations test whether you can screen systematically across the major diagnostic domains, assess risk safely, and build rapport with a patient who may be distressed or guarded. The Mental State Examination (MSE) is observed throughout and documented separately.

Includes:

  • Standardized Psychiatric History Template
  • Headings and Subheadings for Each Section
  • Exact Dialogue Scripts (What to ask)

Edition: 2026 Clinical Format Version

Prepared by: Dr. Raheel Azhar

Communication Tips

  • Use the patient's own words when asking them to expand: "You said you feel empty. Can you tell me more about that?"
  • Prefer nodding to saying "Okay…" after negative statements, which can sound like agreement.
  • Ask about suicide directly and calmly. Asking does not increase the risk.

Comprehensive Psychiatric History Taking Manual

1

Pre-Consultation & Introduction

What to say
"Good morning, I am Dr. [Name], one of the doctors today. Could I confirm your full name and date of birth, please? I have been asked to speak with you today to understand how you've been feeling."

Knock, enter, wash hands, and introduce yourself. Sit at the same level as the patient, at an angle, with a clear route to the door.

2

Verbal Consent

What to say
"Would it be alright if I ask you some questions about how you've been feeling? Some of them may be quite personal. If there's anything you'd rather not answer, just let me know."
3

Confidentiality

What to say
"Everything we discuss today will remain confidential within the team looking after you."
4

Presenting Complaint (PC)

What to ask
"How are you today?"

"Can you tell me what's brought you here today?"

"How have you been feeling recently?"

"Can you tell me more about that?"

"Was it your decision to come today, or did someone suggest it?"

(Allow the patient to explain freely for about 30 seconds, then guide with focused questions. Note the words the patient uses to describe their feelings, and use them in the summary.)

5

History of Presenting Complaint (HPC)

A. Timeline

What to ask
"When did you first notice things weren't right?"

"Did it come on suddenly, or gradually?"

"Has it been getting better, worse, or staying the same?"

"Was anything happening in your life around the time it started?"

"Has anything like this happened before?"
  • Identify onset, duration, course, and triggers, such as bereavement, relationship breakdown, job loss, trauma, childbirth, substance use, or physical illness.

B. Screening for Depression

What to ask
"During the past month, have you been bothered by feeling low, depressed, or hopeless?"

"During the past month, have you had little interest or pleasure in doing things?"
  • If the patient answers yes to either question, continue with the questions below. If they answer no to both but appear low (tearful, flat, withdrawn) or describe other depressive symptoms, continue anyway.

Biological Symptoms

Sleep
What to ask
"How has your sleep been recently?"

"Do you have difficulty getting to sleep?"

"Do you wake up earlier than you usually would, and find it hard to get back to sleep?"
  • Early morning waking means waking at least 2 hours earlier than the patient's usual time and being unable to get back to sleep. It suggests more severe depression. Waking early out of habit or routine does not count.
Mood
What to ask
"How has your mood been recently?"

"On a scale of 0 to 10, where would you put your mood today?"

"Is your mood worse at any particular time of day?"
  • Low mood that is worst in the morning and improves as the day goes on (diurnal variation) is typical of more severe (melancholic) depression.
Appetite and Weight
What to ask
"Have you noticed a change in your appetite?"

"What are you eating on a typical day?"

"Has your weight changed?"
Libido
What to ask
"Since you've been feeling this way, have you noticed any difference in your sex drive?"
Energy / Fatigue
What to ask
"Have you felt more tired than usual, or had less energy?"

"Have you noticed you're moving or thinking more slowly than usual?"

"Or have you felt restless and unable to sit still?"

Cognitive Symptoms

Concentration
What to ask
"How is your concentration? Can you follow a TV programme or read without getting distracted?"
Perception of Current and Future Situation
What to ask
"How do you feel about your current situation?"

"How do you feel about the future?"
Perception of Self
What to ask
"How do you feel about yourself?"

"Do you often criticize or blame yourself when things go wrong?"

"Do you feel guilty about anything?"
  • Hopelessness leads directly into the risk assessment.
  • Severity can be quantified with the PHQ-9, HADS, or BDI-II.

C. Anxiety

What to ask
"Do you often feel anxious, nervous, or on edge?"

"Do you worry about lots of different things and find it hard to stop?"

"Have you had sudden episodes of intense fear, with a racing heart or feeling you might die?"

"Are there places or situations you avoid because they make you anxious?"

"Do you get thoughts that keep coming back even though you try to push them away? Do you feel you have to check or clean things over and over?"

D. Trauma

What to ask
"Have you experienced anything very frightening or upsetting that still affects you now?"

"Do you get memories or dreams of it that feel like you're reliving it?"

E. Screening for Psychosis

What to say
"I ask everyone these next questions as a routine check."
Hallucinations
What to ask
"Have you heard voices when there was no one around, or seen things others couldn't see?"

If yes: "What do the voices say? Do they ever tell you to do things?"

"Have you noticed any sensations in your body that seem odd or hard to explain?"
Delusions
What to ask
"Do you feel people are discussing you negatively?"

"Do you fear that anyone is out to get you or harm you?"

"Have you felt that the TV, radio, or internet is sending you messages?"

"Do you feel you have any special powers or abilities?"
Thought Interference
What to ask
"Do you ever feel thoughts are being put into your head, or taken out of it?"

"Do you feel other people can hear or know what you're thinking?"
  • Command hallucinations to harm self or others are a key risk finding.

F. Screening for Mania / Hypomania

What to ask
"Have there been times when you felt unusually high, energetic, or euphoric?"

"During that time, did you need much less sleep but still feel full of energy?"

"Did your thoughts race, or did people say you were talking faster than usual?"

"Did you do anything out of character, like spending large amounts of money or taking risks?"
  • Ask this in every patient with depression. Missed bipolar disorder leads to inappropriate antidepressant monotherapy.

G. Eating Disorders

What to ask
"Do you worry a lot about your weight or body shape?"

"Do you ever feel you've lost control over how much you eat?"

"Have you ever made yourself sick or used other ways to control your weight?"

H. Organic Causes

What to ask
"Have you had any recent physical illness, head injury, or seizures?"

"Have you been confused, or noticed your memory getting worse?"

"Have you noticed heat or cold intolerance, tremor, or changes in your periods?"
  • New psychiatric symptoms with fluctuating confusion, or in an older patient, are organic until proven otherwise.

I. Risk Assessment

Suicide and Self-Harm

What to ask
"When people feel low, they sometimes feel life isn't worth living. Have you ever felt like that?"

"Have you had any thoughts of ending your life?"

"How often do you have these thoughts?"

"Have you thought about how you would do it? Have you made any plans?"

"Do you have access to the means, such as medications?"

"Have you made any preparations, such as writing a note or giving things away?"

"Have you ever thought about hurting yourself? Have you hurt yourself in any way?"

"Have you ever tried to end your life before?"

If yes: "What happened? Did you expect to die? How did you feel afterwards?"

"Are you drinking alcohol or using drugs at the moment? Did that start before or after you began feeling this way?"

"Have you been able to see friends and socialize recently?"
Protective Factors
What to ask
"What stops you from acting on these thoughts?"

"Who or what keeps you going?"
  • Escalate logically: ideation → frequency → plan → means → preparation → previous attempts.
  • Final acts and regret at survival indicate high intent.
Risk to Others
What to ask
"Have you had any thoughts of harming anyone else?"
Self-Neglect and Vulnerability
What to ask
"Have you been able to look after yourself, eating, washing, and keeping on top of things at home?"

"Is anyone taking advantage of you, or making you feel unsafe?"
Safeguarding
What to ask
"Are there any children or other people who depend on you for care?"

J. Insight

What to ask
"What do you think the cause of the problem is?"

"Do you think you have a problem at the moment?"

"Do you feel you need help with it?"
6

Ideas, Concerns, and Expectations (ICE)

What to ask
"What do you think might be causing how you've been feeling?"

"Is there anything in particular that's worrying you most?"

"What were you hoping we might be able to do for you today?"
7

Past Psychiatric & Past Medical History (PMH)

Past Psychiatric History

What to ask
"Have you ever had other periods of feeling particularly low?"

"Have you ever been told you have depression, or any other mental health condition?"

"Have you ever been seen by a psychiatrist or mental health team?"

"Have you ever been admitted to hospital for your mental health? Was that voluntary?"

"What treatments have you had before, and did they help?"

Past Medical History

What to ask
"Do you have any medical conditions?"

"Are you currently seeing a doctor or specialist regularly?"

"Have you ever had problems with your thyroid, epilepsy, or head injuries?"

"Is there any chance you could be pregnant, or have you had a baby in the last year?"
  • Chronic illness (e.g., chronic pain, cancer) is a major risk factor for depression. Hypothyroidism can directly cause low mood.
8

Past Surgical History (PSH)

What to ask
"Have you had any operations or procedures in the past?"
9

Medication History

What to ask
"Are you taking any prescribed medications or over-the-counter treatments?"

"Are you taking them as prescribed? Have you stopped any recently?"

"Have you noticed any side effects?"

"Do you take any herbal remedies, such as St John's Wort?"

"How much medication do you keep at home?"
  • Record name, dose, frequency, form, and route.
  • Check for drugs that can cause psychiatric symptoms: corticosteroids, isotretinoin, beta-blockers, levodopa, and withdrawal of antidepressants or benzodiazepines.
10

Family History

What to ask
"Have any of your parents or siblings had problems with their mental health?"

"Do you know what kind of problems they had?"

"This is a difficult question, and I'm sorry to have to ask it. Has anyone in your family ever taken their own life?"

"Is there any history of alcohol or drug problems in the family?"
11

Allergy History

What to ask
"Do you have any allergies to medications, foods, or anything else?"

"What exactly happens when you have that reaction?"
12

Social History

Living Situation

What to ask
"What type of accommodation do you live in?"

"Who do you live with?"

"Are there any day-to-day tasks, such as washing, housework, or shopping, that you need help with?"

"Are you under any financial pressure at the moment?"

Relationships and Work

What to ask
"Has your mood affected your friendships or your relationship?"

"Are you working or studying? Has your mood affected your ability to work?"

"Have you had to take any time off because of how you've been feeling?"

Support Network

What to ask
"Have you told anyone how you've been feeling?"

"If you felt overwhelmed or very low, is there anyone you could talk to?"

Alcohol

What to ask
"Do you drink alcohol? What do you drink, how often, and how much in a typical week?"

"Have you ever felt you should cut down on your drinking?"

"Have people annoyed you by criticizing your drinking?"

"Have you ever felt guilty about your drinking?"

"Have you ever had a drink first thing in the morning to steady your nerves?"

Smoking and Recreational Drugs

What to ask
"Do you smoke? How much?"

"Do you use any recreational drugs, such as cannabis or cocaine? How often?"

Gambling

What to ask
"Do you gamble at all? Do you feel it has become a problem?"

Personal History

What to ask
"Could you tell me a little about your childhood and who brought you up?"

"How did you get on at school?"

"Have there been any difficult experiences in your life that still affect you?"

Forensic History

What to ask
"Have you ever been in trouble with the police or had any legal problems?"

If yes: "What happened? Was anyone hurt?"

Premorbid Personality

What to ask
"Before all this started, how would you describe yourself as a person?"

"How do you usually cope when things get difficult?"
13

Travel History

What to ask
"Have you travelled anywhere recently?"
14

Systemic Review

What to ask
"Have you had any headaches, fevers, or changes in your vision?"

"Any palpitations, tremor, or sweating?"

"Any unexplained weight loss?"
15

Patient's Additional Input

What to ask
"Is there anything else you'd like to mention that we haven't discussed?"
16

Summary

What to say
"Thank you for talking so openly. To summarize, you are a [age]-year-old [occupation] who has been feeling [patient's own words] for about [duration], starting around [trigger]. You've noticed [key symptoms], and it has affected [functional impact]. You mentioned [risk findings and protective factors]. Does that sound accurate?"
17

Safety Netting & Follow-up

What to say
"If you start to feel you can't keep yourself safe, or the thoughts of ending your life become stronger, please call your local emergency number, go to the nearest emergency department, or contact a mental health crisis line straight away."

"Can we agree who you would contact if things got worse tonight?"

"I'd also like us to discuss limiting access to [means identified, e.g., stored medications]."

"We'll arrange to see you again on [timeframe], and I'll share today's information with [your GP / the mental health team]. Is that alright with you?"

"Do you have any questions? Thank you for your time today."

Write crisis contacts down for the patient. Dispose of PPE if used, and wash your hands.

Rapid 8-Minute Approach

Work in fixed time blocks. Risk is never cut.

  • 0:00–0:30 | Open: Introduction, consent, confidentiality
  • 0:30–1:00 | Listen: Open question, then about 30 seconds of free talk
  • 1:00–3:30 | Mood: Two screening questions, then SIG E CAPS
  • 3:30–5:00 | Risk: The suicide ladder, then risk to others and dependants
  • 5:00–6:00 | Screen: One or two questions each for mania, psychosis, anxiety, and organic causes
  • 6:00–7:00 | Background: Past psychiatric history, medications, family history, alcohol and drugs, support
  • 7:00–8:00 | Close: Brief ICE, summary, safety net

For a 6-minute station, shorten Mood to about 2 minutes and Background to about 30 seconds. Keep Risk at a full 1.5 minutes.

Mood: SIG E CAPS

Ask "How has your mood been?" first, then:

  • Sleep · Interest · Guilt · Energy · Concentration · Appetite · Psychomotor · Suicide

Mania: DIG FAST

  • Distractibility · Impulsivity · Grandiosity · Flight of ideas · Activity increase · Sleep deficit · Talkativeness

In a short station, one screening question is enough. Expand only if the answer is yes.

Risk: The Suicide Ladder

  • Ideation → Frequency → Plan → Means → Preparation → Previous attempts → Protective factors

Climb the ladder in order. Stop only when the answers are clearly negative.

History-Taking Flow

01 Introduction 02 Consent 03 Confidentiality 04 PC 05 HPC 06 ICE 07 Past Psych & PMH 08 PSH 09 Medications 10 Family Hx 11 Allergies 12 Social Hx 13 Travel 14 Systemic Review 15 Final Additions 16 Summary 17 Safety Net

OSCE Pacing Challenge: Red Flag Injections

Read the clinical vignette, verbalize your "must-not-miss" red flag questions out loud, and then click to reveal the examiner's checklist.

Scenario 1: "A 48-year-old man, recently separated and made redundant, presents with low mood. His sister says he has been giving away his belongings this week."
  • Thoughts of ending life / Plans: (Checking for active suicidal intent)
  • Suicide note / Putting affairs in order: (Checking for final acts indicating high intent)
  • Access to medications or other means at home: (Checking for access to lethal means)
  • Recent alcohol intake: (Checking for alcohol misuse increasing suicide risk)
Scenario 2: "A 26-year-old woman is brought in by her partner after five nights of barely sleeping. She has spent her savings and says she has been chosen for a special mission."
  • Hearing voices / Being told to do things: (Checking for psychotic mania with command hallucinations)
  • Dangerous behaviour to self or others: (Checking for risk from disinhibition)
  • Cocaine or amphetamine use: (Checking for substance-induced mania/psychosis)
  • Possibility of pregnancy: (Checking for pregnancy affecting medication safety)
Scenario 3: "A 31-year-old woman who gave birth 10 days ago is brought in by her mother. She is confused, not sleeping, and says the baby is 'not really hers'."
  • Thoughts of harming herself or the baby: (Checking for suicide and infanticide risk in postpartum psychosis)
  • Voices saying anything about the baby: (Checking for command hallucinations involving the infant)
  • Fever / Unusual discharge since the birth: (Checking for puerperal infection causing delirium)
  • Who is looking after the baby now: (Checking for immediate infant safeguarding)

References

  1. Semple D, Smyth R. Oxford Handbook of Psychiatry. 4th ed. Oxford University Press; 2019.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). APA Publishing; 2022.
  3. National Institute for Health and Care Excellence (NICE). Depression in adults with a chronic physical health problem: recognition and management (CG91). 2009, last updated September 2020.
  4. National Institute for Health and Care Excellence (NICE). Self-harm: assessment, management and preventing recurrence (NG225). 2022.
  5. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613.
  6. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67(6):361–370.
  7. Beck AT, Steer RA, Brown GK. Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation; 1996.

Live Session Score

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History-Taking Flow

01 Introduction 02 Consent 03 Confidentiality 04 PC 05 HPC 06 ICE 07 Past Psych & PMH 08 PSH 09 Medications 10 Family Hx 11 Allergies 12 Social Hx 13 Travel 14 Systemic Review 15 Final Additions 16 Summary 17 Safety Net
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