Shadow health tina jones mental health assessment Subjective Data
shadow health tina jones mental health assessment Subjective Data
Subjective Data Collection: 44 of 44 (100.0%)
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
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A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint
Finding:
Established chief complaint
-  Subjective Action Pro Tip: Foundational questions to open an interview will help the patient tell you what’s bothering her in her own words. Example Question: “what brings you in today?”” data-html=”true” data-title=’Reports difficulty sleeping and “feeling nervous” (Found)’ data-original-title=””>
Finding:
Reports difficulty sleeping and “feeling nervous”
(Found)
Pro Tip: Foundational questions to open an interview will help the patient tell you what’s bothering her in her own words.Example Question:
What brings you in today? -  Subjective Action Pro Tip: Foundational questions will help the patient tell you what’s bothering her in her own words. It is important to ask Tina why she sought treatment to get an understanding of any recent changes with her complaint that could have made it more severe or urgent, prompting her to come in. Example Question: “why did you decide to seek treatment?”” data-html=”true” data-title=’Reports seeking treatment because she has an upcoming exam and feels “too foggy to study” (Found)’ data-original-title=””>
Finding:
Reports seeking treatment because she has an upcoming exam and feels “too foggy to study”
(Found)
Pro Tip: Foundational questions will help the patient tell you what’s bothering her in her own words. It is important to ask Tina why she sought treatment to get an understanding of any recent changes with her complaint that could have made it more severe or urgent, prompting her to come in.Example Question:
Why did you decide to seek treatment? -  Subjective Action Pro Tip: Foundational questions to open an interview will help the patient tell you what’s bothering her in her own words. Tina says that she “feels nervous” before bed, and it is interfering with her sleep. important to ask a follow-up question gain more details about what feeling nervous means her. Example Question: “How do you feel just before bed?”” data-html=”true” data-title=’Reports excessive worry and “racing thoughts” before bed (Available)’ data-original-title=””>
Finding:
Reports excessive worry and “racing thoughts” before bed
(Available)
Pro Tip: Foundational questions to open an interview will help the patient tell you what’s bothering her in her own words. Tina says that she “feels nervous” before bed, and it is interfering with her sleep. It is important to ask a follow-up question to gain more details about what feeling nervous means to her.Example Question:
How do you feel just before bed?
History of Present Illness
Finding:
Asked about onset and duration of symptoms
-  Subjective Action Pro Tip: Determining if the onset of a complaint was gradual or acute is important for diagnosis. In Tina’s case, you will need this information to assess what could be causing her sleep disturbance. Example Question: “how long have you been having trouble sleeping?”” data-html=”true” data-title=”Reports difficulty sleeping began 3 1/2 weeks ago (Found)” data-original-title=””>
Finding:
Reports difficulty sleeping began 3 1/2 weeks ago
(Found)
Pro Tip: Determining if the onset of a complaint was gradual or acute is important for diagnosis. In Tina’s case, you will need this information to assess what could be causing her sleep disturbance.Example Question:
How long have you been having trouble sleeping? -  Subjective Action Pro Tip: Knowledge of the duration of a complaint will help you assess if the issue is recent or chronic. In Tina’s case, you will need this information to assess if she is suffering from chronic insomnia or a more acute sleep disturbance. Example Question: “how long have your sleeping difficulties lasted?”” data-html=”true” data-title=”Reports sleep difficulties have been occurring regularly during past 3 1/2 weeks (Found)” data-original-title=””>
Finding:
Reports sleep difficulties have been occurring regularly during past 3 1/2 weeks
(Found)
Pro Tip: Knowledge of the duration of a complaint will help you assess if the issue is recent or chronic. In Tina’s case, you will need this information to assess if she is suffering from chronic insomnia or a more acute sleep disturbance.Example Question:
How long have your sleeping difficulties lasted?
Finding:
Asked about frequency of symptoms
-  Subjective Action Pro Tip: A precise question the number of occurrences of the issue in an allotted span of time will give you the most accurate estimation of frequency. In Tina’s case, it is important to know that she is suffering sleep disturbances for the majority of nights in a given week. Example Question: “how many nights a week do you have trouble sleeping?”” data-html=”true” data-title=”Reports difficulty sleeping at least four or five times a week (Found)” data-original-title=””>
Finding:
Reports difficulty sleeping at least four or five times a week
(Found)
Pro Tip: A precise question the number of occurrences of the issue in an allotted span of time will give you the most accurate estimation of frequency. In Tina’s case, it is important to know that she is suffering sleep disturbances for the majority of nights in a given week.Example Question:
How many nights a week do you have trouble sleeping?
Finding:
Asked about aggravating factors
-  Subjective Action Pro Tip: An open question about aggravating factors can be used to assess what could be exacerbating the patient’s complaint, as well as her knowledge of those factors. For Tina, it is important to understand what she thinks makes it more difficult for her to fall asleep. Example Question: “what makes it harder to sleep?”” data-html=”true” data-title=”Reports sleeping becomes more difficult when she can not redirect her thoughts from the things she is worried about (Available)” data-original-title=””>
Finding:
Reports sleeping becomes more difficult when she can not redirect her thoughts from the things she is worried about
(Available)
Pro Tip: An open question about aggravating factors can be used to assess what could be exacerbating the patient’s complaint, as well as her knowledge of those factors. For Tina, it is important to understand what she thinks makes it more difficult for her to fall asleep.Example Question:
What makes it harder to sleep? -  Subjective Action Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Though one short nap a day is fine, frequent or extended naps could have been making it more difficult for Tina to fall asleep, and could also indicate an inability to stay awake during her activities of daily living. Example Question: “do you take naps?”” data-html=”true” data-title=”Denies naps during the day (Found)” data-original-title=””>
Finding:
Denies naps during the day
(Found)
Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Though one short nap a day is fine, frequent or extended naps could have been making it more difficult for Tina to fall asleep, and could also indicate an inability to stay awake during her activities of daily living.Example Question:
Do you take naps? -  Subjective Action Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Though caffeine helps Tina to stay alert, drinking too much caffeine could interfere with her sleep. Example Question: “do you drink caffeine?”” data-html=”true” data-title=”Reports drinking caffeine to stay alert (Available)” data-original-title=””>
Finding:
Reports drinking caffeine to stay alert
(Available)
Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Though caffeine helps Tina to stay alert, drinking too much caffeine could interfere with her sleep.Example Question:
Do you drink caffeine? -  Subjective Action Pro Tip: This follow-up question is needed to assess how likely it is that caffeine consumption is interfering with sleep. If Tina were drinking caffeine late in the afternoon or at night, it would very likely be aggravating, or even causing, her sleep disturbance. Example Question: “when do you usually have your last caffeinated drink?”” data-html=”true” data-title=”Reports stopping caffeine use after 4 P.M. (Available)” data-original-title=””>
Finding:
Reports stopping caffeine use after 4 P.M.
(Available)
Pro Tip: This follow-up question is needed to assess how likely it is that caffeine consumption is interfering with sleep. If Tina were drinking caffeine late in the afternoon or at night, it would very likely be aggravating, or even causing, her sleep disturbance.Example Question:
When do you usually have your last caffeinated drink? -  Subjective Action Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Alcohol consumption before bed has been shown to interfere with homeostasis, which regulates sleep, and can even lead to insomnia, so it is important to know if Tina is drinking it to fall asleep. Example Question: “do you drink alcohol before bed?”” data-html=”true” data-title=”Denies alcohol use before bed (Available)” data-original-title=””>
Finding:
Denies alcohol use before bed
(Available)
Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Alcohol consumption before bed has been shown to interfere with homeostasis, which regulates sleep, and can even lead to insomnia, so it is important to know if Tina is drinking it to fall asleep.Example Question:
Do you drink alcohol before bed? -  Subjective Action Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. It is important to know if Tina is using drugs to help her fall asleep because they could, in fact, be contributing to her sleep disturbance. Example Question: “do you use drugs before bed?”” data-html=”true” data-title=”Denies drug use before bed (Available)” data-original-title=””>
Finding:
Denies drug use before bed
(Available)
Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. It is important to know if Tina is using drugs to help her fall asleep because they could, in fact, be contributing to her sleep disturbance.Example Question:
Do you use drugs before bed? -  Subjective Action Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Tina has asthma, and it is important to rule out respiratory issues as a contributing factor to, or even because of, her sleep disturbance. Tina also has an albuterol prescription, which, if she were using it before bed, could be aggravating or causing her anxiety. Example Question: “do you think your sleep problems could be due to breathing issues?”” data-html=”true” data-title=”Reports respiratory problems are controlled and not interfering with sleep (Available)” data-original-title=””>
Finding:
Reports respiratory problems are controlled and not interfering with sleep
(Available)
Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Tina has asthma, and it is important to rule out respiratory issues as a contributing factor to, or even because of, her sleep disturbance. Tina also has an albuterol prescription, which, if she were using it before bed, could be aggravating or causing her anxiety.Example Question:
Do you think your sleep problems could be due to breathing issues?
Finding:
Asked about relieving factors
-  Subjective Action Pro Tip: An open question about alleviating factors can be used to assess what brings relief to the patient, as well as her knowledge of those factors. For Tina, it is important to understand what she thinks makes it easier for her to fall asleep. Example Question: “what helps you sleep?”” data-html=”true” data-title=’Reports sleeping more easily if she can distract herself from her “racing thoughts” (Found)’ data-original-title=””>
Finding:
Reports sleeping more easily if she can distract herself from her “racing thoughts”
(Found)
Pro Tip: An open question about alleviating factors can be used to assess what brings relief to the patient, as well as her knowledge of those factors. For Tina, it is important to understand what she thinks makes it easier for her to fall asleep.Example Question:
What helps you sleep? -  Subjective Action Pro Tip: A closed question about factors known to alleviate the complaint will help you diagnose and treat the issue. Exercise is known to improve sleep, so it is important to assess Tina’s exercise level. Example Question: “do you exercise?”” data-html=”true” data-title=”Reports no exercise (Found)” data-original-title=””>
Finding:
Reports no exercise
(Found)
Pro Tip: A closed question about factors known to alleviate the complaint will help you diagnose and treat the issue. Exercise is known to improve sleep, so it is important to assess Tina’s exercise level.Example Question:
Do you exercise?
Finding:
Asked about impact of sleeping problems on daily living
-  Subjective Action Pro Tip: An open question about the effects of the complaint on a patient’s daily life will help you to get a general idea of the severity of the issue as well as allow you to understand how the patient is dealing with and affected by it. In Tina’s case, though her focus and energy is hampered by her sleep disturbance, she is able to perform all of her usual activities of daily living, meaning her insomnia is not severe, but it is debilitating. Example Question: “how does your lack of sleep affect daily life?”” data-html =true data-title=”Reports feeling tired and “out of it” most of the time during the day due to lack of sleep (Found)” data-original-title=”>
Finding:
Reports feeling tired and “out of it” most of the time during the day due to lack of sleep
(Found)
Pro Tip: An open question about the effects of the complaint on a patient’s daily life will help you to get a general idea of the severity of the issue as well as allow you to understand how the patient is dealing with and affected by it. In Tina’s case, though her focus and energy is hampered by her sleep disturbance, she is able to perform all of her usual activities of daily living, meaning her insomnia is not severe, but it is debilitating.Example Question:
How does your lack of sleep affect your daily life? -  Subjective Action Pro Tip: A closed question about a specific effect on daily life commonly seen with a patient’s complaint can help you to assess severity, diagnose, and treat it. If Tina were falling asleep without intending to, it could indicate a more severe sleep disorder as well as a more debilitating effect on her daily life. Example Question: “have you been falling asleep when didn’t mean to?”” data-html =true data-title=”Reports no increased chance of drifting off during the day despite lack of sleep (Found)” data-original-title=””>
Finding:
Reports no increased chance of drifting off during the day despite lack of sleep
(Found)
Pro Tip: A closed question about a specific effect on daily life commonly seen with a patient’s complaint can help you to assess severity, diagnose, and treat it. If Tina were falling asleep without intending to, it could indicate a more severe sleep disorder as well as a more debilitating effect on her daily life.Example Question:
Have you been falling asleep when you didn’t mean to?
Finding:
Followed up about patient’s experience feeling “out of it”
-  Subjective Action Pro Tip: When a patient uses phrasing that is unclear or not specific enough, it is important to ask a follow-up to ensure your understanding of the issue. Asking Tina what she means by “out of it” will help you to gain a more detailed idea her state mind during the day, and how it is affected by sleep disturbance. Example Question: “What do you mean when you say you feel out of it?”” data-html=”true” data-title=’Reports feeling slowed down and tired, having trouble focusing, and generally feeling “less sharp” (Found)’ data-original-title=””>
Finding:
Reports feeling slowed down and tired, having trouble focusing, and generally feeling “less sharp”
(Found)
Pro Tip: When a patient uses phrasing that is unclear or not specific enough, it is important to ask a follow-up to ensure your understanding of the issue. Asking Tina what she means by “out of it” will help you to gain a more detailed idea of her state of mind during the day, and how it is affected by her sleep disturbance.Example Question:
What do you mean when you say you feel out of it?
Finding:
Asked about anxiety symptoms
-  Subjective Action Pro Tip: If a patient may have anxiety, asking about symptoms will aid diagnosis and determine severity. An open question about how Tina’s anxiety feels will help you to get a general idea of its character. Example Question: “can you tell me about how your anxiety feels?”” data-html=”true” data-title=”Reports feelings of anxiety as “thoughts she can’t turn off” and “being on edge” (available)” data-original-title=””>
Finding:
Reports feelings of anxiety as “thoughts she can’t turn off” and “being on edge”
(Available)
Pro Tip: If a patient may have anxiety, asking about symptoms will aid diagnosis and determine severity. An open question about how Tina’s anxiety feels will help you to get a general idea of its character.Example Question:
Can you tell me about how your anxiety feels? -  Subjective Action Pro Tip: If a patient may have anxiety, a sense of impending doom could indicate a panic disorder. Asking Tina about this will help you to come to a diagnosis and to determine severity. Example Question: “do you ever have a sense of impending doom?”” data-html=”true” data-title=”Reports worry about the future, but no sense of impending doom (Available)” data-original-title=””>
Finding:
Reports worry about the future, but no sense of impending doom
(Available)
Pro Tip: If a patient may have anxiety, a sense of impending doom could indicate a panic disorder. Asking Tina about this will help you to come to a diagnosis and to determine severity.Example Question:
Do you ever have a sense of impending doom? -  Subjective Action Pro Tip: If a patient may have anxiety, it is important to determine if she is having panic attacks. Asking Tina about this will help you to come to a diagnosis and to determine severity, especially if she is experiencing panic before bed. Example Question: “have you been having panic attacks?”” data-html=”true” data-title=”Reports no panic attacks (Found)” data-original-title=””>
Finding:
Reports no panic attacks
(Found)
Pro Tip: If a patient may have anxiety, it is important to determine if she is having panic attacks. Asking Tina about this will help you to come to a diagnosis and to determine severity, especially if she is experiencing panic before bed.Example Question:
Have you been having panic attacks? -  Subjective Action Pro Tip: Difficulty concentrating is an important indicator of generalized or situational anxiety. Asking Tina about this will help you to come to a diagnosis and to determine severity. Example Question: “have you been having trouble concentrating?”” data-html=”true” data-title=”Reports difficulty concentrating due to fatigue from lack of sleep (Available)” data-original-title=””>
Finding:
Reports difficulty concentrating due to fatigue from lack of sleep
(Available)
Pro Tip: Difficulty concentrating is an important indicator of generalized or situational anxiety. Asking Tina about this will help you to come to a diagnosis and to determine severity.Example Question:
Have you been having trouble concentrating? -  Subjective Action Pro Tip: Restlessness is an important indicator of generalized or situational anxiety. Asking Tina about this will help you to come to a diagnosis and to determine severity. Example Question: “do you feel restless?”” data-html=”true” data-title=”Reports only restlessness occurs just before bed (Available)” data-original-title=””>
Finding:
Reports only restlessness occurs just before bed
(Available)
Pro Tip: Restlessness is an important indicator of generalized or situational anxiety. Asking Tina about this will help you to come to a diagnosis and to determine severity.Example Question:
Do you feel restless? -  Subjective Action Pro Tip: Irritability is an important indicator of generalized or situational anxiety. Asking Tina about this will help you to come to a diagnosis and to determine severity. Example Question: “do you feel irritable?”” data-html=”true” data-title=”Reports slight irritability due to fatigue (Available)” data-original-title=””>
Finding:
Reports slight irritability due to fatigue
(Available)
Pro Tip: Irritability is an important indicator of generalized or situational anxiety. Asking Tina about this will help you to come to a diagnosis and to determine severity.Example Question:
Do you feel irritable?
Finding:
Asked about impact of anxiety on daily living
-  Subjective Action Pro Tip: The effects of any complaint on a patient’s daily life are important. Asking Tina about the effects of her anxiety on her daily life will help you to come to a diagnosis and to determine severity. Example Question: “how does your anxiety interfere with daily life?”” data-html =true data-title=”Reports stress only interferes with daily life because it interrupts her sleep (Found)” data-original-title=””>
Finding:
Reports stress only interferes with daily life because it interrupts her sleep
(Found)
Pro Tip: The effects of any complaint on a patient’s daily life are important. Asking Tina about the effects of her anxiety on her daily life will help you to come to a diagnosis and to determine severity.Example Question:
How does your anxiety interfere with your daily life? -  Subjective Action Pro Tip: The effects of any complaint on a patient’s daily life are important. Asking Tina about the effects of her anxiety on her daily life will help you to come to a diagnosis and to determine severity. Example Question: “does your anxiety prevent you from completing usual activities?”” data-html =true data-title=”Reports stress does not prevent her from completing her usual activities (Found)” data-original-title=””>
Finding:
Reports stress does not prevent her from completing her usual activities
(Found)
Pro Tip: The effects of any complaint on a patient’s daily life are important. Asking Tina about the effects of her anxiety on her daily life will help you to come to a diagnosis and to determine severity.Example Question:
Does your anxiety prevent you from completing your usual activities?
Finding:
Asked about sleep quality
-  Subjective Action Pro Tip: Sleep disorders may manifest in different ways, including difficulty falling asleep. In Tina’s case, it is important to know that falling asleep takes more than an hour, while normal sleep latency is only 15-20 minutes. Example Question: “how long does it take you to fall asleep?”” data-html=”true” data-title=”Reports falling asleep often takes more than an hour (Available)” data-original-title=””>
Finding:
Reports falling asleep often takes more than an hour
(Available)
Pro Tip: Sleep disorders may manifest in different ways, including difficulty falling asleep. In Tina’s case, it is important to know that falling asleep takes more than an hour, while normal sleep latency is only 15-20 minutes.Example Question:
How long does it take you to fall asleep? -  Subjective Action Pro Tip: Sleep disorders may manifest in different ways, including frequent awakenings. In Tina’s case, it is important to know how often she is waking often during the night, as well as how long it takes her to fall back asleep. Example Question: “how often do you wake during the night?”” data-html=”true” data-title=’Reports waking up two or three times during the night for “at least ten minutes” (Available)’ data-original-title=””>
Finding:
Reports waking up two or three times during the night for “at least ten minutes”
(Available)
Pro Tip: Sleep disorders may manifest in different ways, including frequent awakenings. In Tina’s case, it is important to know how often she is waking often during the night, as well as how long it takes her to fall back asleep.Example Question:
How often do you wake during the night? -  Subjective Action Pro Tip: In assessing the severity of a sleep disorder, it is important to determine how rested a patient feels when she wakes up in the morning. Tina is waking up feeling tired and “out of it,” meaning her sleep disturbance is having a noticeable effect on quality sleep. Example Question: “How do you feel when you wake up in the morning?”” data-html=”true” data-title=’Reports waking in the morning feeling “out of it” and not rested (Available)’ data-original-title=””>
Finding:
Reports waking in the morning feeling “out of it” and not rested
(Available)
Pro Tip: In assessing the severity of a sleep disorder, it is important to determine how rested a patient feels when she wakes up in the morning. Tina is waking up feeling tired and “out of it,” meaning her sleep disturbance is having a noticeable effect on her quality of sleep.Example Question:
How do you feel when you wake up in the morning?
Finding:
Asked about sleep habits
-  Subjective Action Pro Tip: A specific question about a patient’s bed time will elicit the information you need about when they try to fall asleep. In Tina’s case, it is important to know that she is getting into bed long before she falls asleep. Example Question: “when do you go to bed?”” data-html=”true” data-title=’Reports going to bed “around midnight,” but feeling “too nervous” to sleep (Found)’ data-original-title=””>
Finding:
Reports going to bed “around midnight,” but feeling “too nervous” to sleep
(Found)
Pro Tip: A specific question about a patient’s bed time will elicit the information you need about when they try to fall asleep. In Tina’s case, it is important to know that she is getting into bed long before she falls asleep.Example Question:
When do you go to bed? -  Subjective Action Pro Tip: A specific question about when a patient falls asleep will determine sleep latency as well as how much sleep the patient is actually getting. In Tina’s case, it is important to know that she often falls asleep long after she gets into bed. Example Question: “when do you fall asleep?”” data-html=”true” data-title=”Reports actually falling asleep at 2 or 3 AM (Available)” data-original-title=””>
Finding:
Reports actually falling asleep at 2 or 3 AM
(Available)
Pro Tip: A specific question about when a patient falls asleep will determine sleep latency as well as how much sleep the patient is actually getting. In Tina’s case, it is important to know that she often falls asleep long after she gets into bed.Example Question:
When do you fall asleep? -  Subjective Action Pro Tip: A specific question about what a patient does before bed will help you to assess whether something she is doing could be contributing to the sleep disturbance. In Tina’s case, it is important to know that she reads before bed rather than immediately trying to fall asleep. Example Question: “what do you usually before bed?”” data-html =true data-title=”Reports reading before bed (Found)” data-original-title=””>
Finding:
Reports reading before bed
(Found)
Pro Tip: A specific question about what a patient does before bed will help you to assess whether something she is doing could be contributing to the sleep disturbance. In Tina’s case, it is important to know that she reads before bed rather than immediately trying to fall asleep.Example Question:
What do you usually do before bed? -  Subjective Action Pro Tip: The use of electronics before bed has been shown to stimulate brain activity, which can disturb sleep, and the artificial light from most screens may also affect melatonin levels, which regulate sleep cycles. It is important to know that Tina does not watch television or use a computer before bed to eliminate screen use as a possible contributing factor to her sleep disorder. Example Question: “do you watch television or use the computer before bed?”” data-html=”true” data-title=”Reports no screen use (television or computer) before bed (Available)” data-original-title=””>
Finding:
Reports no screen use (television or computer) before bed
(Available)
Pro Tip: The use of electronics before bed has been shown to stimulate brain activity, which can disturb sleep, and the artificial light from most screens may also affect melatonin levels, which regulate sleep cycles. It is important to know that Tina does not watch television or use a computer before bed to eliminate screen use as a possible contributing factor to her sleep disorder.Example Question:
Do you watch television or use the computer before bed? -  Subjective Action Pro Tip: A specific question about when a patient wakes up can determine if their sleep disturbance is causing early awakening. It is important to know that Tina is waking up at 8 AM, and that it is due to her schedule, not a result of sleep disturbance. Example Question: “when do you usually wake up?”” data-html=”true” data-title=”Reports average wake time of 8 AM (Available)” data-original-title=””>
Finding:
Reports average wake time of 8 AM
(Available)
Pro Tip: A specific question about when a patient wakes up can determine if their sleep disturbance is causing early awakening. It is important to know that Tina is waking up at 8 AM, and that it is due to her schedule, not a result of sleep disturbance.Example Question:
When do you usually wake up? -  Subjective Action Pro Tip: Asking for the average number of hours of sleep a patient gets in one night will elicit the specific information you need to assess the severity of her sleep disorder. In Tina’s case, she is getting less sleep per night than is considered healthy. Example Question: “how many hours of sleep do you get a night?”” data-html=”true” data-title=”Reports sleeping an average of 4 or 5 hours a night (Available)” data-original-title=””>
Finding:
Reports sleeping an average of 4 or 5 hours a night
(Available)
Pro Tip: Asking for the average number of hours of sleep a patient gets in one night will elicit the specific information you need to assess the severity of her sleep disorder. In Tina’s case, she is getting less sleep per night than is considered healthy.Example Question:
How many hours of sleep do you get a night? -  Subjective Action Pro Tip: A patient’s sleep environment can interfere with sleep. It is important to know that Tina has a quiet bedroom to herself to rule out anything from her environment that could be interrupting her sleep with or without her knowledge. Example Question: “can you describe where sleep?”” data-html =true data-title=”Reports sleeping alone in a quiet room (Available)” data-original-title=””>
Finding:
Reports sleeping alone in a quiet room
(Available)
Pro Tip: A patient’s sleep environment can interfere with sleep. It is important to know that Tina has a quiet bedroom to herself to rule out anything from her environment that could be interrupting her sleep with or without her knowledge.Example Question:
Can you describe where you sleep?
Finding:
Asked about stress quality
-  Subjective Action Pro Tip: Stress can mean different things to different patients, so understanding how a patient experiences stress is essential. In Tina’s case, gathering details about her stress can help you to understand if it is situational or chronic, and how it could be aggravating or causing her sleep disturbance. Example Question: “how do you feel when are stressed?”” data-html =true data-title=”Reports feeling nervous and worrying about the future, with racing thoughts (Found)” data-original-title=””>
Finding:
Reports feeling nervous and worrying about the future, with racing thoughts
(Found)
Pro Tip: Stress can mean different things to different patients, so understanding how a patient experiences stress is essential. In Tina’s case, gathering details about her stress can help you to understand if it is situational or chronic, and how it could be aggravating or causing her sleep disturbance.Example Question:
How do you feel when you are stressed?
Medical History
Finding:
Confirmed use of medications
-  Subjective Action Pro Tip: Even if you have seen a patient before, it is important to ask about medications in case they have changed since the last visit. In Tina’s case, a new medication she is taking could be causing or aggravating her sleep disturbance. Example Question: “are you taking any new medications?”” data-html=”true” data-title=”Confirms medications (no new medications reported) (Found)” data-original-title=””>
Finding:
Confirms medications (no new medications reported)
(Found)
Pro Tip: Even if you have seen a patient before, it is important to ask about medications in case they have changed since the last visit. In Tina’s case, a new medication she is taking could be causing or aggravating her sleep disturbance.Example Question:
Are you taking any new medications?
Finding:
Followed up about sleep medication use
-  Subjective Action Pro Tip: Even if you have seen a patient before, it is important to ask about medications in case they have changed since the last visit, especially if they are taking anything to treat their chief complaint. In Tina’s case, asking about over the counter sleep medications is important in understanding possible alleviating factors as well as if an over the counter sleep medication could be contributing to her drowsiness during the day. Example Question: “have you been taking over the counter medications to help sleep?”” data-html =true data-title=”Denies taking OTC sleep medications (Found)” data-original-title=””>
Finding:
Denies taking OTC sleep medications
(Found)
Pro Tip: Even if you have seen a patient before, it is important to ask about medications in case they have changed since the last visit, especially if they are taking anything to treat their chief complaint. In Tina’s case, asking about over the counter sleep medications is important in understanding possible alleviating factors as well as if an over the counter sleep medication could be contributing to her drowsiness during the day.Example Question:
Have you been taking over the counter medications to help you sleep? -  Subjective Action Pro Tip: Even if you have seen a patient before, it is important to ask about medications in case they have changed since the last visit, especially if they are taking anything to treat their chief complaint. If Tina were taking prescription sleep medication, it could indicate that she has seen someone else about her sleep disturbance or that she has been treated for this problem in the past. Example Question: “have you been taking prescribed medication to help sleep?”” data-html =true data-title=”Denies taking prescription sleep medications (Found)” data-original-title=””>
Finding:
Denies taking prescription sleep medications
(Found)
Pro Tip: Even if you have seen a patient before, it is important to ask about medications in case they have changed since the last visit, especially if they are taking anything to treat their chief complaint. If Tina were taking prescription sleep medication, it could indicate that she has seen someone else about her sleep disturbance or that she has been treated for this problem in the past.Example Question:
Have you been taking prescribed medication to help you sleep?
Finding:
Confirmed allergies
-  Subjective Action Pro Tip: It’s best practice to ask a patient about her allergies each visit, even with an established patient, to uncover any new allergy triggers or symptoms. Example Question: “have you had any new allergies?”” data-html=”true” data-title=”Confirms allergies (no new allergies reported) (Found)” data-original-title=””>
Finding:
Confirms allergies (no new allergies reported)
(Found)
Pro Tip: It’s best practice to ask a patient about her allergies each visit, even with an established patient, to uncover any new allergy triggers or symptoms.Example Question:
Have you had any new allergies?
Finding:
Asked about history of sleep problems
-  Subjective Action Pro Tip: Assessing the history of a patient’s present illness is essential to diagnosis and treatment of the complaint. Knowing that until recently Tina hadn’t had similar sleep issues will help you narrow down possible causes. Example Question: “do you have a history of sleep problems?”” data-html=”true” data-title=’Reports usually falls asleep very easily and “sleeps like a log” (Found)’ data-original-title=””>
Finding:
Reports usually falls asleep very easily and “sleeps like a log”
(Found)
Pro Tip: Assessing the history of a patient’s present illness is essential to diagnosis and treatment of the complaint. Knowing that until recently Tina hadn’t had similar sleep issues will help you narrow down possible causes.Example Question:
Do you have a history of sleep problems? -  Subjective Action Pro Tip: Assessing the history of a patient’s present illness is essential to diagnosis and treatment of the complaint. Knowing that Tina had similar sleep problems during a difficult time in her life, and that the problem resolved itself, is integral to diagnosis and treatment. Example Question: “have you had difficulty falling asleep before?”” data-html=”true” data-title=”Reports only past sleep problems occurred for a few months after her father died, but they resolved on their own (Found)” data-original-title=””>
Finding:
Reports only past sleep problems occurred for a few months after her father died, but they resolved on their own
(Found)
Pro Tip: Assessing the history of a patient’s present illness is essential to diagnosis and treatment of the complaint. Knowing that Tina had similar sleep problems during a difficult time in her life, and that the problem resolved itself, is integral to diagnosis and treatment.Example Question:
Have you had difficulty falling asleep before?
Psychological History
Finding:
Asked about history of psychiatric illness
-  Subjective Action Pro Tip: Differentiating between depression and anxiety can sometimes be difficult, and often a patient will have both. Depression is also often a contributing factor in sleep disturbance, and sleep disturbance can also often contribute to depression. If Tina had a history of depression, it could be contributing to her sleep issues. Example Question: “have you ever had depression?”” data-html=”true” data-title=”Denies history of depression (Found)” data-original-title=””>
Finding:
Denies history of depression
(Found)
Pro Tip: Differentiating between depression and anxiety can sometimes be difficult, and often a patient will have both. Depression is also often a contributing factor in sleep disturbance, and sleep disturbance can also often contribute to depression. If Tina had a history of depression, it could be contributing to her sleep issues.Example Question:
Have you ever had depression? -  Subjective Action Pro Tip: Anxiety is a common cause of sleep disturbance, and lack of sleep can also contribute to anxiety issues. If Tina had a history of anxiety, it could be causing or aggravating her current sleep disturbance. Example Question: “do you have a history of anxiety?”” data-html=”true” data-title=”Denies history of anxiety (Found)” data-original-title=””>
Finding:
Denies history of anxiety
(Found)
Pro Tip: Anxiety is a common cause of sleep disturbance, and lack of sleep can also contribute to anxiety issues. If Tina had a history of anxiety, it could be causing or aggravating her current sleep disturbance.Example Question:
Do you have a history of anxiety? -  Subjective Action Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about specific psychiatric disorders to rule them out. Example Question: “do you have a psychiatric illness?”” data-html=”true” data-title=”Denies current psychiatric illness (Available)” data-original-title=””>
Finding:
Denies current psychiatric illness
(Available)
Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about specific psychiatric disorders to rule them out.Example Question:
Do you have a psychiatric illness? -  Subjective Action Pro Tip: As with any patient interview, it is important to ask about any relevant medical history. Tina is here for her mental health, so asking about her history of psychiatric illness is essential. Example Question: “do you have a history of psychiatric illness?”” data-html=”true” data-title=”Denies history of psychiatric illness (Available)” data-original-title=””>
Finding:
Denies history of psychiatric illness
(Available)
Pro Tip: As with any patient interview, it is important to ask about any relevant medical history. Tina is here for her mental health, so asking about her history of psychiatric illness is essential.Example Question:
Do you have a history of psychiatric illness? -  Subjective Action Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about bipolar disorder to rule it out. Example Question: “do you have bipolar disorder?”” data-html=”true” data-title=”Denies bipolar disorder (Available)” data-original-title=””>
Finding:
Denies bipolar disorder
(Available)
Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about bipolar disorder to rule it out.Example Question:
Do you have bipolar disorder? -  Subjective Action Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about schizophrenia to rule it out. Example Question: “do you have schizophrenia?”” data-html=”true” data-title=”Denies schizophrenia (Available)” data-original-title=””>
Finding:
Denies schizophrenia
(Available)
Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about schizophrenia to rule it out.Example Question:
Do you have schizophrenia? -  Subjective Action Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about obsessive compulsive disorder to rule it out. Example Question: “do you have obsessive compulsive disorder?”” data-html=”true” data-title=”Denies obsessive compulsive disorder (Available)” data-original-title=””>
Finding:
Denies obsessive compulsive disorder
(Available)
Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about obsessive compulsive disorder to rule it out.Example Question:
Do you have obsessive compulsive disorder? -  Subjective Action Pro Tip: Even if a patient has not been diagnosed with a psychiatric illness, she could have seen a counselor, therapist, psychologist, or psychiatrist in the past. Asking Tina about past treatment could give you important context for diagnosis. Example Question: “do you have a history of psychiatric illness?”” data-html=”true” data-title=”Denies past psychiatric treatment (Available)” data-original-title=””>
Finding:
Denies past psychiatric treatment
(Available)
Pro Tip: Even if a patient has not been diagnosed with a psychiatric illness, she could have seen a counselor, therapist, psychologist, or psychiatrist in the past. Asking Tina about past treatment could give you important context for diagnosis.Example Question:
Do you have a history of psychiatric illness? -  Subjective Action Pro Tip: Knowledge of past medications is integral to the history of the present illness. Tina is here for a mental health assessment, so it is important to ask her about any past medications for psychiatric illness. Example Question: “have you ever taken psychotropic medication?”” data-html=”true” data-title=”Denies past psychotropic medications (Available)” data-original-title=””>
Finding:
Denies past psychotropic medications
(Available)
Pro Tip: Knowledge of past medications is integral to the history of the present illness. Tina is here for a mental health assessment, so it is important to ask her about any past medications for psychiatric illness.Example Question:
Have you ever taken psychotropic medication?
Finding:
Asked about symptoms to determine depression risk
-  Subjective Action Pro Tip: While a patient with depression does not always know she has it, it is important to ask. If Tina had depression, it could be contributing to her sleep disturbance, or her sleep disturbance could be causing or aggravating or depression. Example Question: “do you have symptoms of depression?”” data-html=”true” data-title=”Reports belief she does not have depression symptoms (Available)” data-original-title=””>
Finding:
Reports belief she does not have depression symptoms
(Available)
Pro Tip: While a patient with depression does not always know she has it, it is important to ask. If Tina had depression, it could be contributing to her sleep disturbance, or her sleep disturbance could be causing or aggravating or depression.Example Question:
Do you have symptoms of depression? -  Subjective Action Pro Tip: Difficulty making decisions is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity. Example Question: “do you have difficulty making decisions?”” data-html=”true” data-title=”Reports no difficulty making decisions (Found)” data-original-title=””>
Finding:
Reports no difficulty making decisions
(Found)
Pro Tip: Difficulty making decisions is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.Example Question:
Do you have difficulty making decisions? -  Subjective Action Pro Tip: An uncharacteristic lack of energy is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity. Example Question: “have you had less energy than usual?”” data-html=”true” data-title=”Reports slightly decreased energy due to lack of sleep (Available)” data-original-title=””>
Finding:
Reports slightly decreased energy due to lack of sleep
(Available)
Pro Tip: An uncharacteristic lack of energy is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.Example Question:
Have you had less energy than usual? -  Subjective Action Pro Tip: Feelings of guilt or worthlessness are important indicators of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity. Example Question: “have you been feeling guilty for no reason?”” data-html=”true” data-title=”Denies feelings of guilt or worthlessness (Available)” data-original-title=””>
Finding:
Denies feelings of guilt or worthlessness
(Available)
Pro Tip: Feelings of guilt or worthlessness are important indicators of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.Example Question:
Have you been feeling guilty for no reason? -  Subjective Action Pro Tip: Feelings of hopelessness are important indicators of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity. Example Question: “have you been feeling hopeless?”” data-html=”true” data-title=”Denies feelings of hopelessness (Found)” data-original-title=””>
Finding:
Denies feelings of hopelessness
(Found)
Pro Tip: Feelings of hopelessness are important indicators of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.Example Question:
Have you been feeling hopeless? -  Subjective Action Pro Tip: A loss of enjoyment in activities usually found enjoyable is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity. Example Question: “have you had trouble enjoying your usual activities?”” data-html=”true” data-title=”Denies loss of enjoyment in activities usually found enjoyable (Available)” data-original-title=””>
Finding:
Denies loss of enjoyment in activities usually found enjoyable
(Available)
Pro Tip: A loss of enjoyment in activities usually found enjoyable is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.Example Question:
Have you had trouble enjoying your usual activities? -  Subjective Action Pro Tip: An unusual increase or decrease in appetite is an important indicator of depression. Asking Tina about this will help you come to a differential diagnosis and determine severity. Example Question: “have you had a change in appetite?”” data-html=”true” data-title=’Reports slightly less appetite because she feels “a little queasy” from lack of sleep (Available)’ data-original-title=””>
Finding:
Reports slightly less appetite because she feels “a little queasy” from lack of sleep
(Available)
Pro Tip: An unusual increase or decrease in appetite is an important indicator of depression. Asking Tina about this will help you come to a differential diagnosis and determine severity.Example Question:
Have you had a change in appetite? -  Subjective Action Pro Tip: Feeling sad is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity. Example Question: “have you been feeling sad?”” data-html=”true” data-title=”Denies feelings of sadness (Available)” data-original-title=””>
Finding:
Denies feelings of sadness
(Available)
Pro Tip: Feeling sad is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.Example Question:
Have you been feeling sad?
Finding:
Asked about suicidal tendencies
-  Subjective Action Pro Tip: When assessing mental health risk factors, it is important to rule out your patient as a suicide risk. Tina would be considered a suicide risk if she had been thinking about or planning to commit suicide. Example Question: “have you ever had suicidal thoughts?”” data-html=”true” data-title=”Denies suicidal thoughts (Found)” data-original-title=””>
Finding:
Denies suicidal thoughts
(Found)
Pro Tip: When assessing mental health risk factors, it is important to rule out your patient as a suicide risk. Tina would be considered a suicide risk if she had been thinking about or planning to commit suicide.Example Question:
Have you ever had suicidal thoughts? -  Subjective Action Pro Tip: When assessing mental health risk factors, it is important to rule out your patient as a suicide risk. Tina would be considered a suicide risk if she had ever engaged in suicidal behavior. Example Question: “have you ever done something that could end your life?”” data-html=”true” data-title=”Denies suicidal behaviors (Available)” data-original-title=””>
Finding:
Denies suicidal behaviors
(Available)
Pro Tip: When assessing mental health risk factors, it is important to rule out your patient as a suicide risk. Tina would be considered a suicide risk if she had ever engaged in suicidal behavior.Example Question:
Have you ever done something that could end your life? -  Subjective Action Pro Tip: When assessing mental health risk factors, it is important to rule out your patient as a suicide risk. Tina would be considered a suicide risk if she had attempted suicide recently or in the past. Example Question: “have you attempted suicide in the past?”” data-html=”true” data-title=”Denies past suicide attempts (Available)” data-original-title=””>
Finding:
Denies past suicide attempts
(Available)
Pro Tip: When assessing mental health risk factors, it is important to rule out your patient as a suicide risk. Tina would be considered a suicide risk if she had attempted suicide recently or in the past.Example Question:
Have you attempted suicide in the past?
Finding:
Asked about self-harm
-  Subjective Action Pro Tip: Self-harm is an indicator of psychiatric disorders as well as a potential risk for suicide. Knowing if Tina has engaged in self-harm is important to assessing her mental health and her safety. Example Question: “have you ever intentionally hurt yourself?”” data-html=”true” data-title=”Denies history of self-harm (Found)” data-original-title=””>
Finding:
Denies history of self-harm
(Found)
Pro Tip: Self-harm is an indicator of psychiatric disorders as well as a potential risk for suicide. Knowing if Tina has engaged in self-harm is important to assessing her mental health and her safety.Example Question:
Have you ever intentionally hurt yourself?
Finding:
Asked about past trauma
-  Subjective Action Pro Tip: Recurring traumatic memories could indicate post-traumatic stress disorder, a significant aspect of a patient’s mental health and well-being. If Tina had traumatic memories, it would be important to assess PTSD as a risk factor. Example Question: “have you ever had repeated, disturbing memories of a stressful experience from the past?”” data-html=”true” data-title=”Denies past trauma (Found)” data-original-title=””>
Finding:
Denies past trauma
(Found)
Pro Tip: Recurring traumatic memories could indicate post-traumatic stress disorder, a significant aspect of a patient’s mental health and well-being. If Tina had traumatic memories, it would be important to assess PTSD as a risk factor.Example Question:
Have you ever had repeated, disturbing memories of a stressful experience from the past?
Finding:
Asked about history of violent thoughts
-  Subjective Action Pro Tip: Difficulty controlling anger is an indicator of psychiatric illness as well as a potential risk to others. Asking Tina about anger is important in assessing her mental health and safety. Example Question: “have you ever had angry outbursts?”” data-html=”true” data-title=”Denies angry outbursts (Available)” data-original-title=””>
Finding:
Denies angry outbursts
(Available)
Pro Tip: Difficulty controlling anger is an indicator of psychiatric illness as well as a potential risk to others. Asking Tina about anger is important in assessing her mental health and safety.Example Question:
Have you ever had angry outbursts? -  Subjective Action Pro Tip: Violence is an indicator of psychiatric illness as well as a potential risk to others. Asking Tina about violence is important in assessing her mental health and safety. Example Question: “have you ever behaved violently?”” data-html=”true” data-title=”Denies past violent behavior (Found)” data-original-title=””>
Finding:
Denies past violent behavior
(Found)
Pro Tip: Violence is an indicator of psychiatric illness as well as a potential risk to others. Asking Tina about violence is important in assessing her mental health and safety.Example Question:
Have you ever behaved violently? -  Subjective Action Pro Tip: Homicidal ideation or a desire to harm others is an indicator of psychiatric illness as well as a potential risk to others. Asking Tina about any potential desire to harm other people is important in assessing her mental health and safety. Example Question: “have you ever wanted to hurt someone else?”” data-html=”true” data-title=”Denies desire to harm others (Available)” data-original-title=””>
Finding:
Denies desire to harm others
(Available)
Pro Tip: Homicidal ideation or a desire to harm others is an indicator of psychiatric illness as well as a potential risk to others. Asking Tina about any potential desire to harm other people is important in assessing her mental health and safety.Example Question:
Have you ever wanted to hurt someone else?
Social History – Education and Work
Finding:
Asked about employment status
-  Subjective Action Pro Tip: It is important to know whether or not a patient is employed when assessing her mental status. In Tina’s case, a change in her employment status could be a result of her mental health, or could be affecting it. The fact that she is employed lets you know she is financially secure, but it could also mean work is a source of her stress. Example Question: “are you employed?”” data-html=”true” data-title=”Currently employed (Found)” data-original-title=””>
Finding:
Currently employed
(Found)
Pro Tip: It is important to know whether or not a patient is employed when assessing her mental status. In Tina’s case, a change in her employment status could be a result of her mental health, or could be affecting it. The fact that she is employed lets you know she is financially secure, but it could also mean work is a source of her stress.Example Question:
Are you employed? -  Subjective Action Pro Tip: A patient’s employment can be an indicator of financial stability, education level, personal interests, and level of responsibility. In Tina’s case, a different workplace could signal instability in her life, which could be a source of her stress. The fact that she is still employed by the same company indicates stability in this area of her life. Example Question: “where do you work?”” data-html=”true” data-title=”Works for a shipping company (Found)” data-original-title=””>
Finding:
Works for a shipping company
(Found)
Pro Tip: A patient’s employment can be an indicator of financial stability, education level, personal interests, and level of responsibility. In Tina’s case, a different workplace could signal instability in her life, which could be a source of her stress. The fact that she is still employed by the same company indicates stability in this area of her life.Example Question:
Where do you work? -  Subjective Action Pro Tip: A patient’s work schedule is an indicator of her financial situation, as well as how demanding her employment may be on her time. In Tina’s case, her work schedule could be contributing to her stress levels. Example Question: “how many hours a week do you work?”” data-html=”true” data-title=”Works 32 hours a week (Available)” data-original-title=””>
Finding:
Works 32 hours a week
(Available)
Pro Tip: A patient’s work schedule is an indicator of her financial situation, as well as how demanding her employment may be on her time. In Tina’s case, her work schedule could be contributing to her stress levels.Example Question:
How many hours a week do you work? -  Subjective Action Pro Tip: Mental health issues can cause a patient to miss work; anxiety and depression, for instance, can make a patient less able to perform her daily responsibilities. If Tina were missing work lately, it could be an important indicator of a change in her mental health status. Example Question: “how often do you miss work?”” data-html=”true” data-title=”Reports rarely missing work (Available)” data-original-title=””>
Finding:
Reports rarely missing work
(Available)
Pro Tip: Mental health issues can cause a patient to miss work; anxiety and depression, for instance, can make a patient less able to perform her daily responsibilities. If Tina were missing work lately, it could be an important indicator of a change in her mental health status.Example Question:
How often do you miss work?
Finding:
Asked about education and learning ability
-  Subjective Action Pro Tip: A patient’s educational history can be an important indicator of economic and mental status, as well as her personal history and interests and any past developmental issues she may have had. In Tina’s case, she is about to achieve an educational milestone, which is a partial source of her stress, so it is especially important to ask her about it. Example Question: “what is your highest education level?”” data-html=”true” data-title=”About to receive B.A. in Accounting (Found)” data-original-title=””>
Finding:
About to receive B.A. in Accounting
(Found)
Pro Tip: A patient’s educational history can be an important indicator of economic and mental status, as well as her personal history and interests and any past developmental issues she may have had. In Tina’s case, she is about to achieve an educational milestone, which is a partial source of her stress, so it is especially important to ask her about it.Example Question:
What is your highest education level? -  Subjective Action Pro Tip: A patient’s past developmental issues can be important indicators of mental status. Asking Tina about past specialized education is an important part of understanding her development. Example Question: “did you ever take special education classes?”” data-html=”true” data-title=”Denies past special education courses (Available)” data-original-title=””>
Finding:
Denies past special education courses
(Available)
Pro Tip: A patient’s past developmental issues can be important indicators of mental status. Asking Tina about past specialized education is an important part of understanding her development.Example Question:
Did you ever take special education classes? -  Subjective Action Pro Tip: A patient’s past learning issues can be important indicators of mental status. Asking Tina about learning differences is an important part of understanding her development. Example Question: “do you have any learning differences?”” data-html=”true” data-title=”Denies learning disabilities (Available)” data-original-title=””>
Finding:
Denies learning disabilities
(Available)
Pro Tip: A patient’s past learning issues can be important indicators of mental status. Asking Tina about learning differences is an important part of understanding her development.Example Question:
Do you have any learning differences? -  Subjective Action Pro Tip: A patient’s speech development can be an important indicator of mental status. Asking Tina about speech difficulties is an important part of understanding her development. Example Question: “do you have difficulties with speech?”” data-html=”true” data-title=”Denies speech problems (Available)” data-original-title=””>
Finding:
Denies speech problems
(Available)
Pro Tip: A patient’s speech development can be an important indicator of mental status. Asking Tina about speech difficulties is an important part of understanding her development.Example Question:
Do you have difficulties with speech? -  Subjective Action Pro Tip: A patient’s hearing ability can be an important indicator of her mental status. Asking Tina about her hearing is an important part of understanding her development. Example Question: “do you have hearing difficulties?”” data-html=”true” data-title=”Denies hearing problems (Available)” data-original-title=””>
Finding:
Denies hearing problems
(Available)
Pro Tip: A patient’s hearing ability can be an important indicator of her mental status. Asking Tina about her hearing is an important part of understanding her development.Example Question:
Do you have hearing difficulties?
Finding:
Asked about hobbies
-  Subjective Action Pro Tip: A patient’s hobbies can help you to get to know her personality and interests better. Any recent change in hobbies, or a loss of interest in them, could indicate a change in mental health. Asking Tina about hobbies is also important in assessing her stress levels and the demands of her current schedule. Example Question: “what do you for fun?”” data-html =true data-title=”Hobbies are reading and watching television (Found)” data-original-title=””>
Finding:
Hobbies are reading and watching television
(Found)
Pro Tip: A patient’s hobbies can help you to get to know her personality and interests better. Any recent change in hobbies, or a loss of interest in them, could indicate a change in mental health. Asking Tina about hobbies is also important in assessing her stress levels and the demands of her current schedule.Example Question:
What do you do for fun?
Finding:
Asked about legal history
-  Subjective Action Pro Tip: Recent or past legal issues are considered a significant indicator of mental status. If Tina had had any recent legal issues, it could indicate an important change in her mental health. Example Question: “have you ever had a legal problem?”” data-html=”true” data-title=”Denies past legal issues (Found)” data-original-title=””>
Finding:
Denies past legal issues
(Found)
Pro Tip: Recent or past legal issues are considered a significant indicator of mental status. If Tina had had any recent legal issues, it could indicate an important change in her mental health.Example Question:
Have you ever had a legal problem?
Finding:
Asked about military service
-  Subjective Action Pro Tip: The demands and experiences of military service can have a profound effect on a patient’s mental health. If Tina had a history of military service, it would be an important part of understanding her feelings of stress and anxiety, and would indicate a need to explore the possibility of PTSD and other trauma. Example Question: “have you served in the military?”” data-html=”true” data-title=”Denies military service (Found)” data-original-title=””>
Finding:
Denies military service
(Found)
Pro Tip: The demands and experiences of military service can have a profound effect on a patient’s mental health. If Tina had a history of military service, it would be an important part of understanding her feelings of stress and anxiety, and would indicate a need to explore the possibility of PTSD and other trauma.Example Question:
Have you served in the military?
Social History – Housing and Support Network
Finding:
Asked about living situation
-  Subjective Action Pro Tip: A patient’s housing is an indicator of finances and comfort. If Tina had recently undergone a change in housing, it could be contributing to her stress. Example Question: “can you tell me about your housing?”” data-html=”true” data-title=”Lives in a house (Found)” data-original-title=””>
Finding:
Lives in a house
(Found)
Pro Tip: A patient’s housing is an indicator of finances and comfort. If Tina had recently undergone a change in housing, it could be contributing to her stress.Example Question:
Can you tell me about your housing? -  Subjective Action Pro Tip: A patient who lives with friends or family has a definite support system, so it is important to ask her about her living situation. If Tina had recently stopped living with her mother and sister, or if living with family were causing problems, this could be contributing to her stress. Example Question: “do you live with anyone?”” data-html=”true” data-title=”Lives at home with mother and sister (Found)” data-original-title=””>
Finding:
Lives at home with mother and sister
(Found)
Pro Tip: A patient who lives with friends or family has a definite support system, so it is important to ask her about her living situation. If Tina had recently stopped living with her mother and sister, or if living with family were causing problems, this could be contributing to her stress.Example Question:
Do you live with anyone?
Finding:
Asked about family dynamics
-  Subjective Action Pro Tip: A patient’s siblings can form part or all of her support network, and her relationship with them can indicate mental health status and/or childhood experiences, so asking about them is important. Tina lives with her sister and sees her brother often, which means they could be a source of support or stress for her. Example Question: “do you have siblings?”” data-html=”true” data-title=”Has a brother and a sister (Available)” data-original-title=””>
Finding:
Has a brother and a sister
(Available)
Pro Tip: A patient’s siblings can form part or all of her support network, and her relationship with them can indicate mental health status and/or childhood experiences, so asking about them is important. Tina lives with her sister and sees her brother often, which means they could be a source of support or stress for her.Example Question:
Do you have siblings? -  Subjective Action Pro Tip: A patient’s parents can form part or all of her support network, and her relationship with them can indicate mental health status and/or child experiences, so asking about them is important. Tina lost her father almost two years ago, so assessing her feelings about that loss is important to assessing her mental health. Tina also lives with her mother, so their relationship could be an important source of support or stress. Example Question: “can you tell me about your parents?”” data-html=”true” data-title=”Father died in a car accident almost two years ago (Available)” data-original-title=””>
Finding:
Father died in a car accident almost two years ago
(Available)
Pro Tip: A patient’s parents can form part or all of her support network, and her relationship with them can indicate mental health status and/or child experiences, so asking about them is important. Tina lost her father almost two years ago, so assessing her feelings about that loss is important to assessing her mental health. Tina also lives with her mother, so their relationship could be an important source of support or stress.Example Question:
Can you tell me about your parents? -  Subjective Action Pro Tip: How a patient gets along with family is an important indicator of the existence of a support network, childhood experiences, and/or mental health. Tina sees her family as her responsibility, but also as a source of support, so it is important to ask her about them in order to assess if they could be contributing to her stress. Example Question: “does your family get along well?”” data-html=”true” data-title=’Reports family is “tight knit” and gets along well (Found)’ data-original-title=””>
Finding:
Reports family is “tight knit” and gets along well
(Found)
Pro Tip: How a patient gets along with family is an important indicator of the existence of a support network, childhood experiences, and/or mental health. Tina sees her family as her responsibility, but also as a source of support, so it is important to ask her about them in order to assess if they could be contributing to her stress.Example Question:
Does your family get along well?
Finding:
Asked about support network
-  Subjective Action Pro Tip: It is important to ask a patient about her support network, including her friends. Asking Tina about her relationships with her friends is also important in assessing her stress levels and the demands of her current schedule. Example Question: “who are your friends?”” data-html=”true” data-title=”Reports close group of friends from middle and high school as well as from church (Found)” data-original-title=””>
Finding:
Reports close group of friends from middle and high school as well as from church
(Found)
Pro Tip: It is important to ask a patient about her support network, including her friends. Asking Tina about her relationships with her friends is also important in assessing her stress levels and the demands of her current schedule.Example Question:
Who are your friends? -  Subjective Action Pro Tip: It is important to ask a patient about her support network, including her friends. Asking Tina about her relationships with her friends is also important in assessing her stress levels and the demands of her current schedule. Example Question: “how often do you spend time with friends?”” data-html=”true” data-title=’Spends time with friends “a few times a month,” though less so with her recent schedule (Available)’ data-original-title=””>
Finding:
Spends time with friends “a few times a month,” though less so with her recent schedule
(Available)
Pro Tip: It is important to ask a patient about her support network, including her friends. Asking Tina about her relationships with her friends is also important in assessing her stress levels and the demands of her current schedule.Example Question:
How often do you spend time with friends?
Finding:
Asked about spirituality
-  Subjective Action Pro Tip: Spirituality can be a significant factor in a patient’s mental status and coping strategies. Tina is a lifelong Baptist and regularly attends church, so it is important to ask her about her spirituality in order to assess her mental health. Example Question: “what are your religious beliefs?”” data-html=”true” data-title=”Identifies as Baptist (Found)” data-original-title=””>
Finding:
Identifies as Baptist
(Found)
Pro Tip: Spirituality can be a significant factor in a patient’s mental status and coping strategies. Tina is a lifelong Baptist and regularly attends church, so it is important to ask her about her spirituality in order to assess her mental health.Example Question:
What are your religious beliefs? -  Subjective Action Pro Tip: Spirituality can be a significant factor in a patient’s mental status and coping strategies. Tina is a lifelong Baptist and regularly attends church, so it is important to ask her about her spirituality in order to assess her mental health. Example Question: “do you attend church regularly?”” data-html=”true” data-title=”Reports attending Baptist church regularly since childhood (Found)” data-original-title=””>
Finding:
Reports attending Baptist church regularly since childhood
(Found)
Pro Tip: Spirituality can be a significant factor in a patient’s mental status and coping strategies. Tina is a lifelong Baptist and regularly attends church, so it is important to ask her about her spirituality in order to assess her mental health.Example Question:
Do you attend church regularly?
Social History – Substance Use
Finding:
Asked about substance use
-  Subjective Action Pro Tip: Substance abuse can be an indicator of, or a contributing factor to, psychiatric illness. Assessing Tina’s history of drug use is important to understanding her risk factors. Example Question: “have you ever used drugs?”” data-html=”true” data-title=”Reports past marijuana use (Found)” data-original-title=””>
Finding:
Reports past marijuana use
(Found)
Pro Tip: Substance abuse can be an indicator of, or a contributing factor to, psychiatric illness. Assessing Tina’s history of drug use is important to understanding her risk factors.Example Question:
Have you ever used drugs? -  Subjective Action Pro Tip: Substance abuse can be an indicator of, or a contributing factor to, psychiatric illness. Assessing Tina’s current drug use is important to understanding her risk factors. Example Question: “do you currently use drugs?”” data-html=”true” data-title=”Denies current substance use (Found)” data-original-title=””>
Finding:
Denies current substance use
(Found)
Pro Tip: Substance abuse can be an indicator of, or a contributing factor to, psychiatric illness. Assessing Tina’s current drug use is important to understanding her risk factors.Example Question:
Do you currently use drugs?
Finding:
Followed up on past marijuana use
-  Subjective Action Pro Tip: How long a patient used drugs can help you to assess any possibilities of addiction or relapse, as well as any potential negative effects on her physical or mental health. Asking Tina how long she smoked marijuana could help you to understand how her past drug use fits into her psychiatric history. Example Question: “how long did you smoke marijuana?”” data-html=”true” data-title=’Reports smoking marijuana for “five or six years” (Available)’ data-original-title=””>
Finding:
Reports smoking marijuana for “five or six years”
(Available)
Pro Tip: How long a patient used drugs can help you to assess any possibilities of addiction or relapse, as well as any potential negative effects on her physical or mental health. Asking Tina how long she smoked marijuana could help you to understand how her past drug use fits into her psychiatric history.Example Question:
How long did you smoke marijuana? -  Subjective Action Pro Tip: Any past substance use can be considered a risk factor, but if a patient had recently stopped using drugs it could indicate a potential for relapse or that drug use could still be affecting her mental health. Asking Tina how long ago she stopped smoking marijuana could help you to understand how her past drug use fits into her psychiatric history. Example Question: “when did you stop smoking marijuana?”” data-html=”true” data-title=’Reports last smoked marijuana when she was “20 or 21″ years old (Found)’ data-original-title=””>
Finding:
Reports last smoked marijuana when she was “20 or 21” years old
(Found)
Pro Tip: Any past substance use can be considered a risk factor, but if a patient had recently stopped using drugs it could indicate a potential for relapse or that drug use could still be affecting her mental health. Asking Tina how long ago she stopped smoking marijuana could help you to understand how her past drug use fits into her psychiatric history.Example Question:
When did you stop smoking marijuana? -  Subjective Action Pro Tip: A patient may have stopped using substances due to adverse effects on her mental and physical wellbeing. Asking Tina why she stopped smoking marijuana could help you to understand how her substance use affected her mentally and physically. Example Question: “why did you stop smoking marijuana?”” data-html=”true” data-title=”Reports quitting marijuana because it “just wasn’t fun anymore” and was bad for her asthma (available)” data-original-title=””>
Finding:
Reports quitting marijuana because it “just wasn’t fun anymore” and was bad for her asthma
(Available)
Pro Tip: A patient may have stopped using substances due to adverse effects on her mental and physical wellbeing. Asking Tina why she stopped smoking marijuana could help you to understand how her substance use affected her mentally and physically.Example Question:
Why did you stop smoking marijuana? -  Subjective Action Pro Tip: A patient may use substances as a form of self-medication for psychiatric illness. Asking Tina why she smoked marijuana could help you to understand how her past drug use fits into her psychiatric history. Example Question: “why did you smoke marijuana?”” data-html=”true” data-title=”Reports marijuana use was for recreation, not to treat or mitigate specific symptoms (Available)” data-original-title=””>
Finding:
Reports marijuana use was for recreation, not to treat or mitigate specific symptoms
(Available)
Pro Tip: A patient may use substances as a form of self-medication for psychiatric illness. Asking Tina why she smoked marijuana could help you to understand how her past drug use fits into her psychiatric history.Example Question:
Why did you smoke marijuana?
Finding:
Asked about alcohol use
-  Subjective Action Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina’s alcohol use could be a risk factor, so it is important to assess her alcohol consumption in order to rule out addiction or dependency. Example Question: “do you drink alcohol?”” data-html=”true” data-title=”Confirms alcohol use (Found)” data-original-title=””>
Finding:
Confirms alcohol use
(Found)
Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina’s alcohol use could be a risk factor, so it is important to assess her alcohol consumption in order to rule out addiction or dependency.Example Question:
Do you drink alcohol? -  Subjective Action Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina drinks alcohol, so it is important to ask her follow-up questions in order to rule out dependency and addiction when assessing her mental health. Knowing how often she drinks alcohol will help you to asses if her use of it is a risk factor. Example Question: “how often do you drink alcohol?”” data-html=”true” data-title=’Reports going out “a couple times a month” (Found)’ data-original-title=””>
Finding:
Reports going out “a couple times a month”
(Found)
Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina drinks alcohol, so it is important to ask her follow-up questions in order to rule out dependency and addiction when assessing her mental health. Knowing how often she drinks alcohol will help you to asses if her use of it is a risk factor.Example Question:
How often do you drink alcohol? -  Subjective Action Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina drinks alcohol, so it is important to ask her follow-up questions in order to rule out dependency and addiction when assessing her mental health. Knowing how much alcohol she drinks will help you to asses if her use of it is a risk factor. Example Question: “how much alcohol do you drink?”” data-html=”true” data-title=’Reports having “a few drinks” when she goes out (Found)’ data-original-title=””>
Finding:
Reports having “a few drinks” when she goes out
(Found)
Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina drinks alcohol, so it is important to ask her follow-up questions in order to rule out dependency and addiction when assessing her mental health. Knowing how much alcohol she drinks will help you to asses if her use of it is a risk factor.Example Question:
How much alcohol do you drink? -  Subjective Action Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina drinks alcohol, so it is important to ask her follow-up questions in order to rule out dependency and addiction when assessing her mental health. It is essential, when checking for risk of alcohol dependency, to ask specific questions in order to discern exactly how many drinks she has per month. Example Question: “how many drinks do you have per month?”” data-html=”true” data-title=”Reports 10-12 alcoholic drinks per month (Found)” data-original-title=””>
Finding:
Reports 10-12 alcoholic drinks per month
(Found)
Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina drinks alcohol, so it is important to ask her follow-up questions in order to rule out dependency and addiction when assessing her mental health. It is essential, when checking for risk of alcohol dependency, to ask specific questions in order to discern exactly how many drinks she has per month.Example Question:
How many drinks do you have per month? -  Subjective Action Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Asking Tina why she drinks alcohol can help you to rule out self-medication and/or dependency. Example Question: “why do you drink alcohol?”” data-html=”true” data-title=’Reports drinking to “relax and blow off steam” (Available)’ data-original-title=””>
Finding:
Reports drinking to “relax and blow off steam”
(Available)
Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Asking Tina why she drinks alcohol can help you to rule out self-medication and/or dependency.Example Question:
Why do you drink alcohol? -  Subjective Action Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. If people close to Tina had asked her to stop drinking, it would be an important indicator of possible alcohol dependency. Example Question: “has anyone asked you to stop drinking?”” data-html=”true” data-title=”Denies that anyone has asked her to stop drinking (Available)” data-original-title=””>
Finding:
Denies that anyone has asked her to stop drinking
(Available)
Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. If people close to Tina had asked her to stop drinking, it would be an important indicator of possible alcohol dependency.Example Question:
Has anyone asked you to stop drinking? -  Subjective Action Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. If Tina felt guilty after drinking, it could indicate she was drinking too much, and/or engaging in risky or uncharacteristic behavior when under the influence, which would be an important indicator of possible alcohol dependency. Example Question: “do you ever feel guilty after drinking?”” data-html=”true” data-title=”Denies guilt associated with drinking (Available)” data-original-title=””>
Finding:
Denies guilt associated with drinking
(Available)
Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. If Tina felt guilty after drinking, it could indicate she was drinking too much, and/or engaging in risky or uncharacteristic behavior when under the influence, which would be an important indicator of possible alcohol dependency.Example Question:
Do you ever feel guilty after drinking?
Finding:
Asked about drinking and driving
-  Subjective Action Pro Tip: Driving under the influence is dangerous, and it can indicate alcohol dependency. If Tina were driving drunk, or riding in cars with a drunk driver, it would indicate alcohol dependency as a risk factor. Example Question: “how do you get home when have been drinking?”” data-html =true data-title=”Reports that she and her friends “usually take a cab” (Found)” data-original-title=”>
Finding:
Reports that she and her friends “usually take a cab”
(Found)
Pro Tip: Driving under the influence is dangerous, and it can indicate alcohol dependency. If Tina were driving drunk, or riding in cars with a drunk driver, it would indicate alcohol dependency as a risk factor.Example Question:
How do you get home when you have been drinking?
Finding:
Asked about tobacco use
-  Subjective Action Pro Tip: Tobacco can affect mental health, so it is important to ask a patient about her tobacco use. Asking Tina about tobacco is recommended because it can contribute to stress and feelings of anxiety. Example Question: “have you ever used tobacco?”” data-html=”true” data-title=”Denies history of tobacco use (Found)” data-original-title=””>
Finding:
Denies history of tobacco use
(Found)
Pro Tip: Tobacco can affect mental health, so it is important to ask a patient about her tobacco use. Asking Tina about tobacco is recommended because it can contribute to stress and feelings of anxiety.Example Question:
Have you ever used tobacco? -  Subjective Action Pro Tip: Tobacco can affect mental health, so it is important to ask a patient about her tobacco use. Asking Tina about tobacco use is recommended because tobacco can contribute to stress and feelings of anxiety. Example Question: “do you use tobacco?”” data-html=”true” data-title=”Denies current tobacco use (Found)” data-original-title=””>
Finding:
Denies current tobacco use
(Found)
Pro Tip: Tobacco can affect mental health, so it is important to ask a patient about her tobacco use. Asking Tina about tobacco use is recommended because tobacco can contribute to stress and feelings of anxiety.Example Question:
Do you use tobacco?
Finding:
Asked about prescription drug abuse
-  Subjective Action Pro Tip: Abuse of prescription drugs can be an indicator of, or a contributing factor to, psychiatric illness. If Tina were abusing prescription drugs it would be a definite risk factor for her mental health. Example Question: “have you taken drugs not prescribed to you?”” data-html=”true” data-title=”Denies prescription drug abuse (Found)” data-original-title=””>
Finding:
Denies prescription drug abuse
(Found)
Pro Tip: Abuse of prescription drugs can be an indicator of, or a contributing factor to, psychiatric illness. If Tina were abusing prescription drugs it would be a definite risk factor for her mental health.Example Question:
Have you taken drugs not prescribed to you?
Social History – Relationship and Sexual History
Finding:
Asked about relationship status
-  Subjective Action Pro Tip: Romantic and sexual relationships are an important part of a patient’s support system, but they can also be a source or indicator of stress. If Tina were in a relationship, it would be important to follow-up for more details on the nature and quality of that relationship. Example Question: “are you in a relationship?”” data-html=”true” data-title=”Currently single (Found)” data-original-title=””>
Finding:
Currently single
(Found)
Pro Tip: Romantic and sexual relationships are an important part of a patient’s support system, but they can also be a source or indicator of stress. If Tina were in a relationship, it would be important to follow-up for more details on the nature and quality of that relationship.Example Question:
Are you in a relationship?
Finding:
Asked about relationship history
-  Subjective Action Pro Tip: Understanding a patient’s relationship history is integral to assessing her mental health. In Tina’s case, a change in her relationship status could be a source of her current stress. Example Question: “have you been in a relationship the past?”” data-html =true data-title=”Reports past relationships (Found)” data-original-title=””>
Finding:
Reports past relationships
(Found)
Pro Tip: Understanding a patient’s relationship history is integral to assessing her mental health. In Tina’s case, a change in her relationship status could be a source of her current stress.Example Question:
Have you been in a relationship in the past? -  Subjective Action Pro Tip: Understanding a patient’s relationship history is integral to assessing her mental health. In Tina’s case, a change in her relationship status could be a source of her current stress. Example Question: “when was your last relationship?”” data-html=”true” data-title=”Last relationship ended three years ago (Found)” data-original-title=””>
Finding:
Last relationship ended three years ago
(Found)
Pro Tip: Understanding a patient’s relationship history is integral to assessing her mental health. In Tina’s case, a change in her relationship status could be a source of her current stress.Example Question:
When was your last relationship? -  Subjective Action Pro Tip: Understanding a patient’s relationship history is integral to assessing her mental health. In Tina’s case, a change in her relationship status could be a source of her current stress. Example Question: “how long was your last relationship?”” data-html=”true” data-title=”Most recent relationship lasted three years (Available)” data-original-title=””>
Finding:
Most recent relationship lasted three years
(Available)
Pro Tip: Understanding a patient’s relationship history is integral to assessing her mental health. In Tina’s case, a change in her relationship status could be a source of her current stress.Example Question:
How long was your last relationship? -  Subjective Action Pro Tip: Understanding a patient’s marital history is integral to assessing her mental health. If Tina had been married, it could be a current source of her stress. Example Question: “have you ever been married?”” data-html=”true” data-title=”Reports she has never been married (Available)” data-original-title=””>
Finding:
Reports she has never been married
(Available)
Pro Tip: Understanding a patient’s marital history is integral to assessing her mental health. If Tina had been married, it could be a current source of her stress.Example Question:
Have you ever been married?
Finding:
Asked about sexual history
-  Subjective Action Pro Tip: Understanding a patient’s sexual history and experiences is integral to assessing her mental health. If Tina had anxiety about her sexual history, it could indicate past trauma, or if Tina had a recent change in her sexual pattern it could indicate a change in her mental status. Example Question: “have you had sex in the past?”” data-html=”true” data-title=”Reports past sexual relationships (Available)” data-original-title=””>
Finding:
Reports past sexual relationships
(Available)
Pro Tip: Understanding a patient’s sexual history and experiences is integral to assessing her mental health. If Tina had anxiety about her sexual history, it could indicate past trauma, or if Tina had a recent change in her sexual pattern it could indicate a change in her mental status.Example Question:
Have you had sex in the past? -  Subjective Action Pro Tip: Understanding a patient’s sexual history and experiences is integral to assessing her mental health. If Tina had anxiety about her sexual history, it could indicate past trauma, or if Tina had a recent change in her sexual pattern it could indicate a change in her mental status. Example Question: “how many sexual partners have you had?”” data-html=”true” data-title=”Reports three previous sexual partners (Available)” data-original-title=””>
Finding:
Reports three previous sexual partners
(Available)
Pro Tip: Understanding a patient’s sexual history and experiences is integral to assessing her mental health. If Tina had anxiety about her sexual history, it could indicate past trauma, or if Tina had a recent change in her sexual pattern it could indicate a change in her mental status.Example Question:
How many sexual partners have you had? -  Subjective Action Pro Tip: Understanding a patient’s sexual history and experiences is integral to assessing her mental health. If Tina had anxiety about her sexual history, it could indicate past trauma, or if Tina had a recent change in her sexual pattern it could indicate a change in her mental status. Example Question: “when did you last have sex?”” data-html=”true” data-title=”Reports last sexual encounter was with boyfriend three years ago (Available)” data-original-title=””>
Finding:
Reports last sexual encounter was with boyfriend three years ago
(Available)
Pro Tip: Understanding a patient’s sexual history and experiences is integral to assessing her mental health. If Tina had anxiety about her sexual history, it could indicate past trauma, or if Tina had a recent change in her sexual pattern it could indicate a change in her mental status.Example Question:
When did you last have sex?
Finding:
Asked about abuse history
-  Subjective Action Pro Tip: A history of abuse can have an enormous effect on a patient’s mental health. If Tina had suffered abuse, it could mean her feelings of stress and anxiety were related to that past trauma. Example Question: “do you have a history of abuse?”” data-html=”true” data-title=”Denies history of abuse (Found)” data-original-title=””>
Finding:
Denies history of abuse
(Found)
Pro Tip: A history of abuse can have an enormous effect on a patient’s mental health. If Tina had suffered abuse, it could mean her feelings of stress and anxiety were related to that past trauma.Example Question:
Do you have a history of abuse? -  Subjective Action Pro Tip: Physical abuse can have an enormous effect on a patient’s mental health. If Tina had suffered abuse, it could mean her feelings of stress and anxiety were related to that past trauma. Example Question: “have you ever been physically abused?”” data-html=”true” data-title=”Denies past physical abuse (Found)” data-original-title=””>
Finding:
Denies past physical abuse
(Found)
Pro Tip: Physical abuse can have an enormous effect on a patient’s mental health. If Tina had suffered abuse, it could mean her feelings of stress and anxiety were related to that past trauma.Example Question:
Have you ever been physically abused? -  Subjective Action Pro Tip: Verbal abuse can have an enormous effect on a patient’s mental health. If Tina had suffered abuse, it could mean her feelings of stress and anxiety were related to that past trauma. Example Question: “have you ever been verbally abused?”” data-html=”true” data-title=”Denies past verbal abuse (Found)” data-original-title=””>
Finding:
Denies past verbal abuse
(Found)
Pro Tip: Verbal abuse can have an enormous effect on a patient’s mental health. If Tina had suffered abuse, it could mean her feelings of stress and anxiety were related to that past trauma.Example Question:
Have you ever been verbally abused?
Social Determinants of Health
Finding:
Asked about stress causes
-  Subjective Action Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: “what seems to be causing your stress?”” data-html=”true” data-title=”Reports feeling stressed about studying and the future (Found)” data-original-title=””>
Finding:
Reports feeling stressed about studying and the future
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
What seems to be causing your stress? -  Subjective Action Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: “what test are you trying to study for?”” data-html=”true” data-title=”Reports CPA professional qualifying exam in one month (Found)” data-original-title=””>
Finding:
Reports CPA professional qualifying exam in one month
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
What test are you trying to study for? -  Subjective Action Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: “what about the future is causing you stress?”” data-html=”true” data-title=”Reports upcoming graduation from college and need to secure employment (Found)” data-original-title=””>
Finding:
Reports upcoming graduation from college and need to secure employment
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
What about the future is causing you stress?
Finding:
Asked about stress coping
-  Subjective Action Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: “how do you cope with stress?”” data-html=”true” data-title=”Reports coping with stress by going to church (Found)” data-original-title=””>
Finding:
Reports coping with stress by going to church
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
How do you cope with stress? -  Subjective Action Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: “how do you manage stress?”” data-html=”true” data-title=”Reports coping with stress by staying organized (Found)” data-original-title=””>
Finding:
Reports coping with stress by staying organized
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
How do you manage stress? -  Subjective Action Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: “who do you talk to about stress?”” data-html=”true” data-title=”Reports coping with stress by talking to friends and family (Found)” data-original-title=””>
Finding:
Reports coping with stress by talking to friends and family
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Who do you talk to about stress? -  Subjective Action Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: “do your coping strategies help stress?”” data-html =true data-title=”Reports usual stress coping strategies are less effective (Found)” data-original-title=””>
Finding:
Reports usual stress coping strategies are less effective
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Do your coping strategies help your stress?
Family History
Finding:
Asked about relevant family history
-  Subjective Action Pro Tip: Many psychiatric illnesses are hereditary, so knowing the patient’s family psychiatric history is essential to assessing her mental health. In Tina’s case, a family history of anxiety or depression could be significant in reaching a diagnosis. Example Question: “has anyone in your family had a psychiatric illness?”” data-html=”true” data-title=”Denies psychiatric illness in the family (Found)” data-original-title=””>
Finding:
Denies psychiatric illness in the family
(Found)
Pro Tip: Many psychiatric illnesses are hereditary, so knowing the patient’s family psychiatric history is essential to assessing her mental health. In Tina’s case, a family history of anxiety or depression could be significant in reaching a diagnosis.Example Question:
Has anyone in your family had a psychiatric illness? -  Subjective Action Pro Tip: Substance abuse and addiction often runs in families, so knowing the patient’s family history of substance abuse is essential to assessing her mental health. In Tina’s case, a significant family history of addiction could be considered a risk factor. Example Question: “do you have a family history of alcohol dependency?”” data-html=”true” data-title=’Reports uncle has a “problem with alcohol” (Available)’ data-original-title=””>
Finding:
Reports uncle has a “problem with alcohol”
(Available)
Pro Tip: Substance abuse and addiction often runs in families, so knowing the patient’s family history of substance abuse is essential to assessing her mental health. In Tina’s case, a significant family history of addiction could be considered a risk factor.Example Question:
Do you have a family history of alcohol dependency? -  Subjective Action Pro Tip: Substance abuse and addiction often runs in families, so knowing the patient’s family history of substance abuse is essential to assessing her mental health. In Tina’s case, a significant family history of addiction could be considered a risk factor. Example Question: “do you have a family history of drug addiction?”” data-html=”true” data-title=”Denies family history of drug addiction (Available)” data-original-title=””>
Finding:
Denies family history of drug addiction
(Available)
Pro Tip: Substance abuse and addiction often runs in families, so knowing the patient’s family history of substance abuse is essential to assessing her mental health. In Tina’s case, a significant family history of addiction could be considered a risk factor.Example Question:
Do you have a family history of drug addiction? -  Subjective Action Pro Tip: Depression and other psychiatric illnesses can be hereditary, and the suicide of a family member can also be a source of psychiatric trauma, so knowing a patient’s family history of suicide is essential to assessing her mental health. If Tina had a family history of suicide, it could be considered a risk factor. Example Question: “has anyone in your family committed suicide?”” data-html=”true” data-title=”Denies family history of suicide (Available)” data-original-title=””>
Finding:
Denies family history of suicide