Case History

You might also like

Download as pdf or txt
Download as pdf or txt
You are on page 1of 3

Identifying / Family Information

Tell me about your family.

Describe any close friend or social relationships.

Why don't you have any close friends?

Tell me about your current living situation.

Who do you live with?

Do you have a social security number?

Describe a typical day for you.

Do you have any felony convictions?

Are you a US citizen?

Areas of Concern
How long have you been working with occupational therapy, either in a group or one-on-one?

Talk about your OT goals and progress since you started working one-on-one with the OT at the shelter.

Is there a reason that you're not making eye contact with me?

What, if anything, is difficult about being in your apartment?

Tell me about your history of homelessness.

Why didn't you have enough money to pay for your own housing?

How did you end up getting into a shelter for housing?

Describe your experience in the OT clinic at the homeless shelter.

Developmental
Tell me about your childhood.

Did you experience fetal drug exposure?

Were you neglected as a child?

Medical
Describe your medical history.

You describe pins and needles from the neuropathy. Do you have any pain?

Tell me about any mental health diagnoses you have received.


What type of psychosis do you experience?

Where do you go to get your healthcare?

What types of doctors do you see now?

Describe whether you see a psychiatrist or other mental health professional.

Are you addicted to drugs?

Describe where you access dental care.

Tell me about the medications you take and how you’re doing with your medication routine.

Psychosocial
Have you been experiencing sadness or periods of depressed mood?

Do you have any suicidal ideations?

Tell me about your motivation to do things.

Do you feel worthless since you don’t have a job?

Do you experience grandiose thoughts?

Activities of Daily Living


Describe how you get food on a daily basis.

Do you have a favorite food?

Why don't you ask your family to help you with meals?

Do you have any difficulty completing or keeping up with your self-care like dressing, bathing, and
grooming?

Instrumental Activities of Daily Living


Describe what type of transportation you use to get around.

How are you doing with managing your apartment?

Describe how you get money on a regular basis.

What is the usual amount of spending money you have per month?

How do you make sure your bills are paid every month?

Can you tell me where you keep your checkbook?

Describe whether you use a phone or other means to communicate with people.

Can you afford a phone with unlimited text and talk?

What would you do in case of a general emergency in your apartment?

What would you do if there was a fire?

Education and Work


Do you currently have a job?
Don’t you want to work?

Why are you applying for disability?

How many years of school did you complete?

Tell me about some of the previous jobs you have held.

Social, Play, Leisure


What do you like to do socially or for fun?

Why don't you get involved in a hobby?

Rest and Sleep


Do you find you're sleeping better now that you’re in your own apartment?

Do you self-medicate to help you fall asleep?

You might also like