CASE RECORD FILE (CRF)

PROFORMA

CRF NO - DATE:

Name :
Age :
Sex
Father’s Name / husband’s Name :

Education :
Occupation:

Marital status :
Religion :

Mother tongue :
Residence – {Rural/ sub urban / urban state}

Family income:
Family : Nuclear/ joint/ living alone/
Address :

Source of referral:

Previous consultation :

Identification mark: (recent photo)- scar, mole, and tattoo:

Consent :

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Patient’s Report
Reliability and adequacy
Chief complaints:
1.

2.

3.

4.

5.

History of present illness:

Predisposing
Precipitating
Perpetuating
Limiting
Modifying factors

Mode of onset: abrupt, acute, and insidious

Course of illness: continuous, episodic, fluctuating
Progress: Deteriorating, static, improving

Patient’s pervasive and persistent mood

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History of present illness:

Informants’ report
Reliability and adequacy
Reliability – contact, consistency, continuity, corraborativeness, constancy.
Presenting complains
1.

2.

3.

4.

5.

History of present illness:

Predisposing
Precipitating
Perpetuating
Limiting
Modifying factors

Mode of onset: abrupt, acute, and insidious

Course of illness: continuous, episodic, fluctuating
Progress: Deteriorating, static, improving

Patient’s pervasive and persistent mood

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Time line and illness graph:

  4  
Impact of illness on patient’s attitude

Role functioning –

Biological functions:
sleep
appetite
weight loss
libido
sexual function.
Important negative history

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Treatment history:
Psychiatrists, physicians, faith healers, hospitalization
Medicines:

Dose, duration, best response, side effect, adherence to medicines, reason to poor adherence

Drug Name Dose Duration Response Side effect

Past history:
Illness graph
Mood graph
Inter episodic function and deficit

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Family history:
Consanguinity between parents, first-degree relatives - age, education, occupation, personality
Genogram (pedigree analysis) – 3 generations

Family members living together, interpersonal relations, family support system

Mental illness

Mental retardation
Suicide
Epilepsy
Movement disorders
Substance abuse
Dementia
Other neurological disorders- HC, essential tremors
HTN, diabetes, thyroid

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Personal history:
Birth and early development:

Presence of childhood disorder: ADHD, Autism, conduct,

Home atmosphere: Stepparents, broken home, adopted sibling, patient attitude towards parents

Scholastic and extracurricular activities:

Age and entry to school
Involvement in games and extracurricular activities:
Conflict with authority figure
Failures
Change in school:

Occupational history:
Duration, position held, reason of leaving, relation with colleagues, promotions and comparison to
colleagues

Sexual and marital history:

Early curiosity, infantile masturbation, sex play,

Forensic history:

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PREMORBID PERSONALITY: (Mayer and Gross)
(patients, relatives, others) source and reliability

SELF/ INTELLECTUAL ABILITY: hobbies and interest

SOCIAL RELATION: Family, friend group, society and work

MOOD:
cheerful vs sad,
worry vs placid,
optimism vs pessimism,
stable vs unstable

CHARACTER :
i. Attitude towards work and responsibility, hope
ii. Inter-personal relation:
Self confident vs shy
Insensitive vs sensitive to criticism
Trust vs suspiciousness, jealous
Controlled vs short tempered, irritable,
Adaptive vs non adaptive
iii. Moral: standard and religiosity
iv. Energy and initiative

HABITS:
Veg, non-veg, substance, self-medication, sleep pattern

FANTASY LIFE – frequency and daydreaming

Harm Avoidance, Reward Dependence, Novelty Seeking, Persistence

Self directedness, self transcendence, judgment

Cluster A Cluster B C luster C

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Mental status examination: language of interview interpreter
1. General appearance: kempt and tidy, unkempt and untidy, sickly,
perplexed (duration and severity of illness)

General physical appearance, body build, dress (cultural background and economic status), hygiene,
grooming…

Touch with surroundings (present/partial/absent)

eye contact (present/partial/absent) facial expression, Posture

Attitude:
Cooperative
Uncooperative/ defensive
Evasive: escape from arguments and shift topics
Guarded: restrict information
Suspicious:
Hostile:
Overfamiliar:
Seductive:
others (specify)

Rapport : easily established, established with difficulty, not established.

2. Behaviour : reduced or increased motor activity

Catatonic features (Bush and Francis Catatonia Rating Scale), Kirby’s method

Abnormal movement and postures, involuntary movements (

tremors, dystonia, dyskinesia, chorea, athetosis) – AIMS, Simpson Angus scale SAS

3. Speech:
Intensity ,tone, quality, prosody, reaction time, relevance, coherence, goal direction, productivity

4. Affect : subjective and objective (a/c to Tasman)

I. Quality-
ii. Range – restricted, blunt, flat
iii. Mobility – constricted, fixed
iv. Reactivity – reactive or non reactive
V. Communicability- communicable or poorly communicable
Vi. Congruence – mood congruent or mood in-congruent
Vii. Appropriateness: to thoughts

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5.Thought: record verbatim sample of speech
stream – prolixity, flight of idea, pressured speech, retardation, circumstantiality, tangentiality,
perseveration, thought blocking

form – formal thought disorder, loosing of association, derailment , neologism

procession- obsessions, thought echo, withdrawal, insertion, broadcast.

contents –primary delusion (delusional perception, sudden delusional idea), secondary

delusion- delusion of reference, persecution, grandeur, control, love, infidelity, bizarre

6.Perception:
Sensory distortion
Illusion -
Hallucination- Auditory, visual, tactile, olfactory, gustatory, Autoscopy

Other phenomena: depersonalization, derealization, and body image disturbance

7.Judgment: Test, social, personal judgment
8.Insight:
Grade I - Complete denial of illness
Grade II - Slight awareness of being sick but denying at the same time
Grade III - Awareness of being sick but blaming it on external factors
Grade IV - Due to something unknown to patient
Grade V - Intellectual insight
Grade VI - True emotional insight

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Diagnostic formulation:

Diagnosis:
ICD10/DSM IV
Points in favors and against , differential diagnosis

TREATMENT PLAN:

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