PSYCHOLOGICAL CASE HISTORY SHEET

Department of Applied Psychology,

GC University, Faisalabad.

Reg.No _________________
Date: ___________________
Name _______________________________ S/o, D/o, W/o _____________________________

Age: _____________Grade: _____________ Education: ________________________________

Occupation: ___________________________ Marital Status: ___________________________
Siblings: ___________ Sister(s): ____________ Brother(s): ___________ Birth Order: _______
Occupation (Father’s)
No of children (if yes): ___________Son(s): _____________ Daughter(s): _________________
Present Address: ________________________________________________________________

_____________________________ Ph No: __________________Cell No: _________________

Socio Economic Status: Upper ___________ Middle _______________ Lower _____________
Referral Source ________________________________________________________________

PRESENTING COMPLAINTS (nature of problems. precipitating event. patients feelings and

thoughts about problems) _________________________________________________________
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HISTORY OF PROBLUMS (duration of resent problem, changes in nature. intensity and /or
frequency of problem over time, prodromal manifestations, others past problems of a
psychological nature, no. of attacks) ________________________________________________
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PRIOR TREATMENT (details of treatment) ________________________________________
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PSYCHIATRIC/ MEDICAL HISTORY: _________________________________________

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FAMILY HISTORY OF ILLNESS:_______________________________________________

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FAMILY HISTORY (migrations, births, marriages, serious illness, jobs of earning, members,
relationships with family members) _________________________________________________
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BIRTH: (normal, caesarian, instrumental etc) ________________________________________

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HISTORY OF PRENATAL DEVELOPMENT & MILESTONES:_____________________

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WORK HISTORY: (nature and duration of job, reason for job change, relationship with

Colleagues) ___________________________________________________________________
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HISTORY OF RELATIONSHIPS (family, peers. friends, marital, colleagues, bosses, etc)

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SCHOOL HISTORY: __________________________________________________________

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GENERAL MENTAL STATE EXAMINATION (Orientation, Attention, Memory etc)

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PERCEPTION (illusions, hallucinations-auditory, visual, tactile, Somatic, olfactory)

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THOUGHT: __________________________________________________________________
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AFFECT: (crying spells, depression, guilt feelings, suicidal, excited, hostile, grandiosity,
blunted affect)
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SLEEP: (insomnia, sleep, walking, night, mares) _____________________________________
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BEHAVIOR: (speech, mute, talkative, abusive, restless etc)

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MENARISM AND POSTURING: (usual gestures, preservative movements)

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ANXIETY: (tension, nervousness, phobias, obsessions/compulsions)

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SOMATOFORM; (conversion, hypochondrias, other somatic complaints) _________________

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PSYCHOSEXUAL: (gender identity, paraphilias psychosexual dysfunctions)

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PSYCHOSOMATIC: (obesity, headaches painful menstruation, skin disorders, asthina, ulcers,

nausea and vomiting)
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ADDICTIONS:________________________________________________________________
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PERSONALITY TRAITS: (paranoid, schizoid, schizotypal, antisocial, borderline, histrionic,

narcissistic, avoidant, dependent, obsessive, compulsive, passive, aggressive):
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INTERVIEW BEHAVIOUR: (open, anxious, relaxed, withdrawn, cooperative, aggressive,

compliant, opposition) ___________________________________________________________
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STRENGTHS: (degree of insight, motivation, intellectual level, other talents):

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ANY ADDITIONAL INFORMATION: ___________________________________________

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RECOMMENDED PSYCHOLOGICAL TESTS: ___________________________________

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~5~
TENTAIVE DIAGNOSIS: ______________________________________________________
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RECOMMINDED THERAPIES: ________________________________________________

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PROGNOSIS: _________________________________________________________________
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FOLLOW UP SESSIONS: ______________________________________________________

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CONSULTANT PSYCHOLOGIST'S ADVICE: ____________________________________

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FINAL DIAGNOSIS: __________________________________________________________

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DATE OF TERMINATION:
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REASONS OF TERMNATION: _________________________________________________

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Consultant Psychologist

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