4
Diagnosis
Recommended Aspects of the Initial Psychiatric Evaluation
Medical History
• Whether or not the patient has an ongoing relationship with a primary care
health professional
• Allergies or drug sensitivities
• All medications the patient is currently or has recently taken and the side
effects of these medications (i.e., both prescribed and nonprescribed
medications, herbal and nutritional supplements, and vitamins)
• Past or current medical illnesses and related hospitalizations
• Relevant past or current treatments, including surgeries, other procedures,
or complementary and alternative medical treatments
• Sexual and reproductive history
• Cardiopulmonary status
• Past or current neurological or neurocognitive disorders or symptoms
• Past physical trauma, including head injuries
• Past or current endocrinological disease
• Past or current infectious disease, including sexually transmitted diseases,
human immunodeficiency virus (HIV), tuberculosis, hepatitis C, and locally
endemic infectious diseases such as Lyme disease
• Past or current sleep abnormalities, including sleep apnea
• Past or current symptoms or conditions associated with significant pain and
discomfort
• Additional review of systems, as indicated
Family History
• Including history of suicidal behaviors or aggressive behaviors in biological
relatives
Personal and Social History
• Preferred language and need for an interpreter
• Personal/cultural beliefs, sociocultural environment, and cultural
explanations of psychiatric illness
• Presence of psychosocial stressors (e.g., financial, housing, legal, school/
occupational, or interpersonal/relationship problems; lack of social support;
painful, disfiguring, or terminal medical illness)
• Exposure to physical, sexual, or emotional trauma
• Exposure to violence or aggressive behavior, including combat exposure or
childhood abuse
• Legal or disciplinary consequences of past aggressive behaviors
(cont'd)
