Psychosocial History

A psychosocial history is a component of a patient’s medical history that focuses on their psychological and social wellbeing. It involves obtaining information about the patient’s family relationships, social environment, past psychological health, coping abilities, stressors, and other factors influencing their mental health and behavior. A psychosocial history provides context for the patient’s condition, identifies risk factors, and guides diagnosis and treatment planning. Information is gathered through clinical interview, medical records, family input, and screening tools. Key elements in a psychosocial history include family dynamics, trauma/abuse, substance use, mood disorders, chronic stress, role functioning, support systems, cultural factors, and past psychological treatment. Taking a psychosocial history is critical for providing whole-person, patient-centered care.