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Case Record Proforma
Case Record Proforma
Identifying Data:
Name – Miss:G
Age –13.8yrs
Sex –Female
Education –5th Class
Occupation – Student
Marital Status – Unmarried
Socioeconomic Status –Middle Class
Residence – Urban/rural- - VijayawadaUrban
Chief Complaints:
Not getting marks in exam
Not able to read and write properly
Low memory
Low concentration
Onset:abrupt/acute/insidious
Course: continuous
Precipitating Factors/Stressors:
Associated Disturbances:
Negative History:
Past History:
Past Psychiatric history – at age of 3 years she diagnosed with epilepsy from that
till 7 year use medication , latter stopped with doctor suggestion
Personal History:
Birth History – birth cry delayed , parents report that she is everything normal
till 3years , in fever she got seizures , after that onwards the speech vocabulary
not according to the age .
Behaviour during childhood – she is sociable person and parents says no issues
of behavior problems
School History – she went Pre-school at age of 3, at age 5 to Govt., school , still
she is in that same school 5th class .
Her speech vocabulary not up to the age and her finger grip is not proper
Occupational History – she plays her-self , not going out of the home and she
loves plays with children younger than her age . She help mother in household
work , cleaning home and cutting vegetables and other petty things.
Sexual History – No
Premorbid Personality –
Social relations: she speaks good with guest , grant parents and who come
to her home , no friends in class ,
Intellectual activities:
Mood: active and pleasant
Character:
Interpersonal relationships: only with family members
Energy and Initiative: normal and adequate
Habits: playing with cooking toys
Speech:
Tone = soft
Tempo= normal
Volume= Low
Coherence= normal
Relevance= normal
Emotions:
Mood = always in soft and happy
Affect (range, reactivity, intensity, mobility, appropriateness): appropria
Thought:
Form (circumstantiality/tangentiality/ loose associations/Word salad)
Stream (Flight of ideas/ retardation of thinking/ perseveration/ thought
blocking)
Possession (Obsessions and compulsions/ thought
alienation/insertion/deprivation/ broadcasting)
Content
Perception:
She exhibits that her skills not like other in her age
Consciousness:
Orientation:
She have place and time orientation and why she came to this place
Calculations:
She can read and write 100 numbers , single digit additions only
Memory (Immediate, recent, remote):
She did has good memory on live events and movies
She did number repeat till 4 digits and back word 3 digits
Insight: yes
Judgment:
Test –
Social –
Personal –
Age, physical
development
Management Plan:
Referrals
Special Education
Occupational Therapy
Language Therapy
Psychosocial treatment
Social skills training