CASE STUDY

SECTION-I GENERAL INFORMATION

Date : ………………..

 Name: ………………………..

 DOB ष : ……………..

 Age (Year): …………

 Sex: ………….

 Education: ………….

 Referred by: ……………

 Language Spoken: ………….

 History Taken By: …………...

 Present
Address………………………………………………………………

 Contact no.

 Family Income(Per Month) Rs.

 Locality *: (1) Urban (2) Rural

 SECTION-II

Present Complaints
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Onset:
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Previous Consultations-Yes/No (If 'Yes' specify)

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SECTION-III (FAMILY HISTORY)

1) Type of Family * :…………………..

2) Marital Status*:………………….

3)Father Name*:…………………….

 Age *:……………………
 Father's Educational Qualification *:……………………….
 Father's business *:…………………………
 D. Father's monthly income (in Rs.)*:……………………..
4) Mother name*:…………………………….
 A Age*:……………………………….
 B Mother Educational Qualification*:………………………………
 C Mother business*:…………………………

 D Mother monthly income (in Rs.)*:……………………….

Household Composition/(Family and Care Taker)/

Family History of case *:

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Relationship of the above to case

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SECTION-IV (MEDICAL HISTORY)

Prenatal

 Thyriod *
 Rh-Factor *
 Miscarriage/Abortion/Still Birth
 Trauma* Yes /No
 Hypertension* Yes /No
 Drugs (If Taken)* Yes /No
 Bleeding* Yes /No
 Smoking* Yes /No
 Drinking * Yes /No
 Any Other Information:
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Natal
 Delivery
Full Term 2) Premature
 Delivery Conducted By
 Delivery At
 Birth Cry Yes /No
 Color Of Baby
 Any Other Information
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Post natal
 Thyriod

 Trauma

 Convulsion

 History Of Illness

 Test conducted (with results)

 SECTION-V GENERAL SKILLS

Motor skills

Self help skills

Social skills

Attention and concentration

Communication:
 Receptive
 Expressive

Interests

Recreational activity
Status at work/school

Psychological Assessment
Test conducted
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Results
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SECTION-VI

Home Environment

Family Involvement in:

 Personal needs

 Educational or occupational needs

  Play and Leisure Activities

Management Plan