Table 1. Domains of the Clinical Evaluation
Questions to Consider
Reason for the evaluation
What is the patient's chief complaint and
What reason does the patient give for seeking evaluation
at this specific time?
What reasons are given by other involved parties (e.g.,
family, other health professionals) for seeking evaluation at this
History of the present illness
What symptoms is the patient experiencing (e.g., worries; preoccupations;
changes in mood; suspicions; delusions or hallucinatory experiences;
recent changes in sleep, appetite, libido, concentration, memory,
or behavior, including suicidal or aggressive behaviors)?
What is the severity of the patient's symptoms?
Over what time course have these symptoms developed
Are associated features of specific psychiatric syndromes
(i.e., pertinent positive or negative factors) present or absent
during the present illness?
What factors does the patient believe are precipitating,
aggravating, or otherwise modifying the illness or are temporally
related to its course?
Did the patient receive prior treatment for this episode
Are other clinicians who care for the patient available
Past psychiatric history
What is the chronology of past episodes of mental illness,
regardless of whether such episodes were diagnosed or treated?
What are the patient's previous sources of
treatment, and what diagnoses were given?
With respect to somatic therapies (e.g., medications, electroconvulsive
therapy), what were the dose or treatment parameters,
efficacy, side effects, treatment duration, and adherence?
With respect to psychotherapy, what were the type,
frequency, duration, adherence, and patient's perception
of the therapeutic alliance and helpfulness of the psychotherapy?
Is there a history of psychiatric hospitalization?
Is there a history of suicide attempts or aggressive
Are past medical records available to consult?
History of alcohol and other substance use
What licit and illicit substances have been used, in
what quantity, how frequently, and with what pattern and route of
What functional, social, occupational, or legal consequences
or self-perceived benefits of use have occurred?
Has tolerance or withdrawal symptoms been noted?
Has substance use been associated with psychiatric
Are family members available who could provide corroborating information
about the patient's substance use and its consequences?
General medical history
What general medical illnesses are known, including hospitalizations,
procedures, treatments, and medications?
Are undiagnosed illnesses causing major distress or
Does the patient engage in high-risk behaviors that
would predispose him or her to a medical illness?
Is the patient taking any prescribed or over-the-counter
medications, herbal products, supplements, and/or vitamins?
Has the patient experienced allergic reactions to or
severe adverse effects of medications?
Developmental, psychosocial, and sociocultural
What have been the most important events in the patient's
life, and what were the patient's responses to them?
What is the patient's history of formal education?
What are the patient's cultural, religious,
and spiritual beliefs, and how have these developed or changed over
Is there a history of parental loss or divorce; physical,
emotional, or sexual abuse; or exposure to other traumatic experiences?
What strategies for coping has the patient used successfully
during times of stress or adversity?
During childhood or adolescence, did the patient have
risk factors for any mental disorders?
What has been the patient's capacity to maintain
interpersonal relationships, and what is the patient's
history of marital and other significant relationships?
What is the patient's sexual history, including
sexual orientation, beliefs, and practices?
Does the patient have children?
What past or current psychosocial stressors have affected
the patient (including primary support group, social environment,
education, occupation, housing, economic status, and access to health
What is the patient's capacity for self-care?
What are the patient's sociocultural supports
(e.g., family, friends, work, and religious and other community
What are the patient's own interests, preferences,
and values with respect to health care?
Occupational and military history
What is the patient's occupation, and what
jobs has the patient held?
What is the quality of the patient's work
What work skills and strengths does the patient have?
Is the patient unable to work due to disability?
Regarding military service, what was the patient's
status (volunteer, recruit, or draftee), did the patient experience
combat, and did the patient suffer injury or trauma?
Is the patient preparing for or adjusting to retirement?
Does the patient have any past or current involvement
with the legal system (e.g., warrants, arrests, detentions, convictions,
Do past or current legal problems relate to aggressive
behaviors or substance intoxication?
Has the patient had other significant interactions
with the court system (e.g., family court, workers' compensation
dispute, civil litigation, court-ordered psychiatric treatment)?
Is past or current legal involvement a significant
social stressor for the patient?
What information is available about general medical
and psychiatric illnesses, including substance use disorders, in
Is there a family history of suicide or violent behavior?
Are heritable illnesses present in family members that
relate to the patient's presenting symptoms?
Review of systems
Is the patient having difficulty with sleep, appetite,
eating patterns, or other vegetative symptoms, or with pain, neurological symptoms,
or other systemic symptoms?
Does the patient have symptoms that suggest an undiagnosed medical
illness that may be causing or contributing to psychiatric symptoms?
Is the patient experiencing side effects from medications
or other treatments?
What is the appropriate timing, scope, and intensity
of the exam for this patient, and who is the most appropriate examiner?
Upon examination, are there abnormalities in the patient's
general appearance, vital signs, neurological status, skin, or organ systems?
Is more detailed physical examination necessary to
assess the patient for specific diseases?
Mental status examination
What symptoms and signs of a mental disorder is the
patient currently exhibiting?
What are the patient's general appearance
What are the characteristics of the patient's
What are the patient's mood and affect, including
the stability, range, congruence, and appropriateness of affect?
Are the patient's thought processes coherent?
Are there recurrent or persistent themes in the patient's
Are there any abnormalities of the patient's
thought content (e.g., delusions, ideas of reference, overvalued
ideas, ruminations, obsessions, compulsions, phobias)?
Is the patient having thoughts, plans, or intentions
of harming self or others?
Is the patient experiencing perceptual disturbances
(e.g., hallucinations, illusions, derealization, depersonalization)?
What are the patient's sensorium and level
of cognitive function (e.g., orientation, attention, concentration,
registration, short- and long-term memory, fund of knowledge, level
of intelligence, drawing, abstract reasoning, language, and executive
What are the patient's level of insight, judgment,
and capacity for abstract reasoning?
What is the patient's motivation to change
his or her health risk behaviors?
What are the patient's functional strengths,
and what is the disease severity?
To what degree can the patient perform physical activities
of daily living (e.g., eating, toileting, transferring, bathing,
To what degree can the patient perform instrumental
activities of daily living (e.g., driving, using public transportation,
taking medications as prescribed, shopping, managing finances, keeping house,
communicating by mail or telephone, caring for dependents)?
Would a formal assessment of functioning be useful
(e.g., to document deficits or aid continued monitoring)?
What diagnostic tests are necessary to establish or
exclude a diagnosis, aid in the choice of treatment, or monitor
treatment effects or side effects?
Information derived from the interview process
Are symptoms minimized or exaggerated by the patient
Does the patient appear to provide accurate information?
Do particular questions evoke hesitation or signs of
Is the patient able to communicate about emotional
How does the patient respond to the psychiatrist's
comments and behaviors?