YMCA KAMAK Hr. Sec.

School for the Deaf,

Visalakshipuram,
Madurai -14.
CASE - STUDY DETAILS
I. IDENTIFICATION DATA:
photo
1. Name:
2. DOB:
3. Age:
4. Gender:
5. Education: Reg no:
6. Identity card no: Admission no:
7. Aadhaar card no: Referred by:
8. UDID no: Weight:
II.DEMOCRATIC DATA: Height:
1.
Parental Name Age Education Occupation Income
Informatio
n
Father
Mother
Guardian
(specify
relation)

2. Total income of the family (monthly):

3.
Address: Permanent: Temporary:

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4. Phone no.:
5. Place: urban ◯ / rural ◯

6. Community: SC ◯ / BC ◯ / MBC ◯ / ST ◯

7. Religion: Hindu ◯ / Christian ◯ / Muslim ◯ / Others ◯

8. Language:
Mother tongue:
What languages are spoken in home?

III. Child’s information:

1. Person completing this form? Relating to the child?

2. Contacting period between the child and the person?

3. The age of mother when the disabled baby is born?

4. Information available: True ◯ / half true ◯ / not true ◯
5. Information obtained: enough ◯ / not enough ◯
6. Current problems:

7. When was the problem first noticed? By whom?

8. Had any other specialist (physician, psychologist, special

education teachers, etc.) seen the child? If yes, indicate the type of
specialist, when the child was seen, and the specialist conclusions
or suggestions.

IV. EDUCATION HISTORY:

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 1. School:

2. Standard:

3. Teacher:

4. How is the child doing academically?

5. How does the child interact with others?

V. Family History:
1.Family type: nuclear◯ / joint family ◯
2.Family status details: unity ◯ / non unity ◯ / happy ◯
3.Family economic status: poor ◯ / middle class ◯
4.Parental Name Age Education Occupation Income
Informatio
n
Father
Mother
Guardian
(specify
relation)

5. Marriage system:
a) Blood relationship -
b) Close relationship -
Others
6.Does anyone have the family have the following disabilities?
a) Mentally retarded
b) Psychic

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 c) Epilepsy
d) Hearing impaired
e) Multiple disabilities
Others
VI. BIRTH HISTORY:
1.Mother’s general / mental health during pregnancy:
2.Continous testing treatment: GH ◯ / PHC ◯ / Private hospital ◯
3.Have tried abortion?
4.Did any abortion occur?
5.Pregnancy: expected ◯ / unexpected ◯

6.Allergies: Yes ◯ / No ◯

7.Diabetes: Yes ◯ / No ◯
V.PRENATAL:
1.Bleeding: Yes ◯ / No ◯

2.Nutrition: Yes ◯ / No ◯

3.Accidents: Yes ◯ / No ◯

4.Blood pressure: Yes ◯ / No ◯

5.Jaundice: Yes ◯ / No ◯

6.Fetus movements: Good ◯ / not good ◯

7.Sexually transmitted diseases: Yes ◯ / No ◯

8.X – ray: Yes ◯ / No ◯

9.Chemicals: Yes ◯ / No ◯

10.Drugs: Yes ◯ / No ◯
Others
PERINATAL:
Place of Delivery: home ◯ / hospital ◯

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Length of pregnancy: full term ◯ / preterm ◯ / post term ◯

Type of childbirth: normal ◯ / forceps ◯ / caesarian ◯

Has mother faced any problem at labor: Yes ◯ / No ◯

AFTER BIRTH:
Did the mother have any abnormalities during pregnancy?
Yes ○ / No ○

The umbilical cord is rounded: Yes ◯ / No ◯

Weight:
Color: Pink ◯ / Yellow ◯ / Blue◯

Birth cry: Yes ◯ / No ◯

Breathing problem: Yes ◯ / No◯

More than one delivery: Yes ◯ / No ◯

Birth defect: Yes ◯ / No ◯

Infection: Yes ◯ / No ◯

Have there been any feeding problems: Yes ◯ / No ◯

Epilepsy: Yes ◯ / No ◯
PRENATAL:
(yes ✓/no ✕)
Infection
Baby jaundice
Epilepsy
Wound
Lack of nutrition
Immunization
Polio
Throat obstruction

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Tetanus
Measles
Others
Pre training class (give short note): Yes ◯ / No ◯
DEVELOPMENTAL MILESTONES:
Activity Normal Late
development
Head control 2 - 4 months
Sitting 5 - 6 months
Standing 10 - 14 months
Walking 12 - 18 months

Language Normal Late

development
Babbling 6 - 8 months
First word 6 - 8 months
Phrases 16 - 20 months
Simple sentences 3 - 4 years

Social and Normal Late

Behavioral history
Socializes with peers 1 - 4 years
and elders
Turn over 30 - 36 months
Feeds himself/herself 4 - 5 months
Toilet activity 30 - 36 months
Dress himself/herself 4 - 5 years

SELF-HELP SKILLS:
Toilet activity
Dresses and undress himself/herself
Making up himself/herself
Feeds himself/herself
Walking without support

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SENSORY MOTOR SKILLS:
Touching
Tasting
Smelling
Seeing
Hearing
LANGUAGE AND COMMUNICATION SKILLS
Expressive language skills
Receptive language skills
ABILITY TO UNDERSTANDING:
Listening
Identifying objects
Using objects
Following some rules
Awareness of dangers and accidents
IDENTIFYING SKILLS:
Color
Size
Gender
Shape
Numbers
Time
Money
EDUCATIONAL SKILS:
Reading
Writing

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Mathematics
PREVOCATIONAL SKILLS:
Likes
Dislikes
Home activity
LESSURE TIME ACTIVITY:

PRESENT STATUS ABOUT THE CHILD:

EXPECTATION: