Patient History

One of the first steps in any clinical assessment is to gather a thorough history from the patient. This history includes, at minimum, the patient’s identifying information, presenting problem, and relevant personal history relating to their presenting problem.

Identifying Information
Within this section, you will describe basic information on your patient, including the person’s name, sex, gender, sexual orientation, age, race, occupation, and location of residence (country, state, and region).

  1. Chief Complaint/Presenting Problem
    Within this section, you will include the patient’s primary complaint verbatim to identify and describe the main source of his or her distress and/or concerns. If there is no verbatim complaint, include observable information to create an overall picture of the presenting problem. 
    Typically, this section within a psychological report seeks to answer the following question (further elaboration within this section is encouraged where possible):
    • What are the patient’s complaints? (e.g., the patient might complain about “feeling on edge” or experiencing stress)
  2. You will not be completing section III of the Final Paper for this week’s assignment.
  1. Personal History 
    Within this section, you will describe your patient’s personal background and history of abnormal behavior(s) that inform your diagnostic impression. You will also gather information about the patient’s cultural background and cultural norms.

    Typically, this section within a psychological report seeks to answer the following questions (further elaboration within this section is encouraged where possible):
    • Where did the patient grow up?
    • What cultures did the patient experience throughout life?
    • What was the patient’s school life like?
    • What were his or her grades? What is his or her highest level of education?
    • What is the patient’s interpersonal relationship history?
    • What was/is the patient’s romantic relationship history?
    • What was/is the patient’s friendship history?
  2. Family History 
    Within this section, you will describe the patient’s familial relationship(s) and identify any abnormalities that might affect future treatment. You will also integrate information about the patient’s family and cultural background to identify any maladaptive behaviors and relational patterns.

    Typically, this section within a psychological report seeks to answer the following questions (further elaboration within this section is encouraged where possible):
    • How old were the patient’s parents when the patient was born?
    • Who were the patient’s primary caregivers?
    • What was/is family life like? (Include any information relevant to your diagnostic impression.)
    • Did the family move often?
    • What was/is the patient’s relationship with their siblings (if applicable)?
    • What culture did/does the family come from?
    • What belief systems are attached to that culture?
  3. Therapy History 
    Within this section, you will describe the patient’s therapy history to inform your diagnostic impression. Analyze the patient’s therapy history to identify the effectiveness of previous treatment(s). Evaluate previous treatment interventions based on information and knowledge of the patient’s cultural background. 

    Typically, this section within a psychological report seeks to answer the following questions (further elaboration within this section is encouraged where possible):
    • Who was the previous therapist (if any)?
    • How long did the previous therapy/therapies last?
    • What was the patient’s diagnosis?
    • What interventions did the therapist(s) use?
    • Were those interventions appropriate for the patient’s culture?
    • Was treatment successful?

Assignment should include both a title page and reference page, and be of sufficient depth and detail to support and inform your diagnostic impression, with an absolute minimum of four pages (not including the title and reference pages). A cursory or surface level review of the patient’s presenting problem and history will unlikely provide enough information for your diagnostic impression.

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