A Center for Child Development & Learning Enrichment

Plot No.5, Road No.8, Bharathi Nagar. Vijayawada, Andhra Pradesh - 520 008.

IDENTIFICATION DATA
Regd. No:

Date:

Childs Name: ________________________________School & Grade: ________________________

Date of Birth:_____________________________ Age:________________Gender:________________
Address:______________________________________________________________________________
Referring physician: __________________________________ Phone: _________________________
Pertinent Medical Diagnosis: __________________________________________________________
Primary Language: ________________________Other Language spoken:____________________
Reason for referral:____________________________________________________________________
MOTHERS NAME:___________________________________Cell phone:______________________
Mothers occupation: ________________________________Education:______________________
FATHERS NAME:___________ ________________________Cell phone:______________________
Fathers occupation: _________________________________Education:______________________
Email ID: ____________________________________________________________________________
CASE HISTORY
1. PRESENTING COMPLAINTS:
a) .

Informant: Mather/Father/Guardian/Others.

b) .
HISTORY OF PRESENT COMPLAINTS:
(When identified and who informed )

2. PERSONAL HISTORY:

PRENATAL

NATAL

EVENTS

REPORTED

Mother's age at conception

<18yrs / 19 - 34yrs/>35yrs

Regular antenatal check ups

Attended/not attended.

Abortions

Attempt/repeated

Foetal movements

Active/sluggish

Nutritional status of the mother

Adequate/Inadequate

Mother's health
Gestation period

Diabetics, hypertension Convulsion, infection,

swelling, level Of B.P, emotional trauma
Pre / full / post term

Delivery place

Home/hospital/other

Birth cry

Absent/delayed/present

Birth wt

<2.5kg / 2.5kg/ >2.5kg

Birth colour

Pale blue/pink/yellow

Y/N

Any other

POST
NATAL

Nutritional Status

Bottle fed/Breast fed

Feeding Problem

Vomiting/Spitting/difficulty in sucking

Put in incubator due to

Hypoxic/ Asphyxia/Cyanosis/ LBW/ other

complications
Infections/Injury/Convulsions/ Jaundice/ High
Fever/ Abnormal Presentation

Any Events
Congenital Deformities
Immunization

Done/Not Done

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3.FAMILY HISTORY

Marriage

Consanguineous/ Non-consanguineous

Marital Status
Type of Family
Status of Family
No. of Family Members
Socio-economical Status
Residence Type
Parent Child Interaction
History in family

Intact/Discord
Joint/ Nuclear/ Extended
Intact/ Broken/Strained
Low/Middle/High
Own/ Rent, Rural/Urban
Adequate/ inadequate
Mental Retardation/ Mental Illness/
Epile.psy/ VI/ HI/Any Other

4.SCHOOL HISTORY
Age of Admission in School
Type of School Admitted
Present Standard
School Performance
Interactions Teachers / School
mates

Regular/ Special/ Play/ Integrated

Good/Average/ Poor/ Failed

Extra-curricular Activities
Discrepant in subjects
Problem in School
6. OCCUPATIONAL HISTORY
How Child helps the Mother
Working setting
Working Style
Relationship with Co-workers
Nature of Work
If Employed

Interactions
Visiting Family and Neighbours
Participation
Support of external Families

School/ Home/ Shop

Willingness to work in team/
Coordination/ Others
Co-operative/ Non cooperative
Self help, household or any
Age of Entry, Salary and Position hold

7. SOCIAL INVOLVEMENT
Neighbourhood Participation
Social/ Religious Groups
8.PEDIGREE CHART

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INTELLECTUAL ASSESSMENT
1. GENERAL BEHAVIOUR DURING ASSESSMENT
Physical Appearance

Age appropriate/ Thin/ Obese / average

built/ Well dressed
Any Deformity/ toe walk/ typical walk
Maintain/ Poor
Differential Cry/ Postures/ gestures/
Nonverbal/ Non meaningful/
Meaningful/ Verbal in single
words/Two words/ Full Sentences
Clear/Lacks Clarity/ Stuttering/
Stammering
Cooperative/ not cooperative

Neatly, Well Groomed

Eye Contact
Communication

Speech
Behaviour during Assessment

Attention could be

2. ATTENTION AND CONCENTRATION

Aroused/ sustained/ not sustained

Time

Few minutes/ Required time for

completion of task
3. ACTIVITY LEVEL
Aloof/ Awake and Alert/ Dull and
Lethargic/ Restless/ Overactive

Activity

Comprehends
Identifies
Common Objects
Discriminate
(in terms of
_____________________________)
Concept Developed

Mood of the Child

Perceive Mood
Display Emotions (

4. COMPREHENSION
One/ Two/ Three/ Multiple instructions
Familiar Person/ Objects
Identifies / Know the use/ Names
Geometrical Shapes/ Colour/ Size/
Gender/ Number/ Time/ Money
Concrete/ Functional/Abstract level

5. EMOTINALITY AND BEHAVIOUR

Irritability/ Stubborn/ Temperaments/
Pleasant/withdrawn/Fearful
Tone/ Content of others
) Appropriate to the situation/
Exaggerated/ Inadequate/
Behavioural manifestations

6. RELATIONSHIP WITHIN / OUTSIDE FAMILY

Favourable/ Un favourable
Attitude towards the Child
Relationship between the Family
Adequate/ In adequate
Members
Conflicts within the family
Present/ Absent
Psycho-social Stressors
Present/ Absent
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7. TEST ADMINISTERED:
I. DEVELOPMENTAL SCREENING TEST (DST)
2.VINELAND SOCIAL MATURITY TEST (VSMS)
3.SEGUIN FORM BOARD TEST (SFBT)
4.BINET KAMMAT T:EST OF INTELLIGENCE (BKV)
5.MISIC
6.
7.
8. TEST FINDINGS:
1.ON DST:
2.ON VSMS:
3.ON SFBT
4.ON BKT

D.A.:
S.A.:
P.A.:
M.A.:

D.Q.:
S.Q.:
P.Q.:
I.Q.:

9. PROVISIONAL DIAGNOSIS:
INTELLEGENCE QUOTIENT
(I.Q.)

LEVEL OF RETARDATION

PERCENT OF
DISABILITY

10.RECOMMENDATIONS :
SERVICES REQUIRED
FOCUS OF
INTERVENTION
Remedial Education ,
Special Education
Speech Therapy
Physio Therapy
Occupational Therapy
Behaviour Modification
Medical
Referal
BEHAVIOUR PROBLEMS
1. Tearing books, breaking objects throwing objects
2. Rolls over the floor, Screaming cries excessesively
3. Grabs objects from other, spit on others
4. Self injurious: Bang head, scratches self, pull own hair, bites self, peels skin wounds etc
5. Repetitive behaviour: Body rocking, nods headshakes parts of the body, repeatedly
6. Odd behaviour, Smiles laughs or talks to self without reason collect rubbish etc
7. Over activity :Does not sit at one place for require time does not complete the task at hand etc
8. Rebellious behaviour: refuses to obey commands , does opposite of what is requested etc
9. Antisocial behaviour: Steals Cheats in games lies or twists the truth blames others
10. Fear : Fear of places, persons animal s or objects

Summary :
DATE:

Bezawada Institute of Learning Difficulties - CASE HISTORY

SIGNATURE

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