“Comprehensive Psychosocial History Taking: A Step-by-Step Guide for Assessment”

History Taking Process for Psychosocial Assessment

1. Identifying Information:

• Individual/Group: Specify if the case involves an individual or group.
• Environment: Rural or urban.
• Family: History, type, background, income level, and age.

1. Chief Complaint:

• Primary symptoms and reasons for seeking help, identified clinically.
• Mental Status Examination (MSE).
• Doctor’s diagnosis.
• Provisional diagnosis: Focusing on a biopsychosocial assessment to differentiate between thoughts and feelings.

1. Psychometric Testing:

• Name of the test and findings used for history taking.

1. Case Handling:

• Specify reasons and methods for addressing the case.
• Assess memory, motivation, decision-making, anger levels, and psychological outlook.

1. Chief Complaints/Worries:

• Key concerns and issues raised by the client.

1. Sources of Complaints:

• Explore the origins of the chief complaints.

1. History of Present Concern:

• Discuss the client’s concept of wellbeing, identity issues, and mismatched personal resources.
• Onset, precipitating factors, and internal/external factors maintaining the concern.

1. Past History:

• Major stressful events and strategies used to manage them.

1. Family History:

• Current and past problems faced by family members.
• Client’s perception of these family issues.

1. Significant Others Outside the Family:
   • Any major problems faced by significant others and the client’s perception of their own problems.
2. Personal History:
   • Physical: Sleep, appetite, and other physical factors.
   • Emotional: Types and intensity of difficult emotions.
   • Interpersonal Relationships: Parents, siblings, grandparents, peers, intimate relations.
   • Occupational: Goals, demands, resources, and achievements.
   • Lifestyle: Stress moderators and enhancers.
   • Sexual History: Development, abuse, habits, and preferences.
   • Fantasies and Values: Key influences on behavior and thought processes.
3. Cognitive Process Techniques:
   • Track progress through each session, covering biological, psychological, and social aspects.
   • Note significant learning and summarize changes.
4. Acknowledgement:
   • Analyze family relationships and family maps for better understanding.