History

Information is obtained from a variety of sources, including the patient's self-report, observations of family members or close friends, medical records, and prior evaluations from academic or work situations. Information is obtained regarding (1) past medical history, including illnesses, injuries, surgeries, medications, hospitalizations, substance abuse, and relevant family medical history, (2) past psychiatric history, including hospitalizations, medications, and outpatient treatment, (3) developmental background, including circumstances of gestation, birth and delivery, acquisition of developmental milestones, and early socialization skills, (4) social development, including major autobiographical events and relationships (a three-generation genogram is highly useful in gaining relevant family information), (5) educational background, including early school experiences and academic performance during high school, college, postgraduate study, and other educational and technical training (the presence of a learning disability should be assessed) (6) vocational history, including work performance, work satisfaction, and relationships with supervisors and co-workers, and (7) recreational interests and hobbies.

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