CASE HISTORY FORM

 General Information Date:

Name: Date of Birth:

Age:

Address: Phone:

City: Zip:

Referred By: Phone:

Reason for Referral:

 Pre Natal and Birth History: Comments

Was pregnancy full term? Y N

Any medications taken during Y N

pregnancy?
Any complications with pregnancy? Y N
or delivery?
Any special care required at birth? Y N
(i.e. oxygen, intubation)

 Medical History:
Comments
Ear Infections? Y N

Hearing aid? Y N
Hearing Evaluation Y N Date: Results:
completed?
Need for Y N
eyeglasses?
Ocular motor/ eye Y N
problems?
Serious illness, Y N Dates:
injury, or falls?
Frequent colds or Y N
sinus problems?
Upper respiratory Y N
infections?

 Physical History:
Does the child have any current diagnoses? Yes / No. If Yes, list:

Any falls, significant injuries or surgeries? Yes / No. If Yes, list:

 Developmental History:
Provide the approximate age at which the child began to do the following
activities:
 Crawl:
 Sit:
 Stand:
 Walk:
 Feed self:
 Dress Self:
 Use toilet:
 Use single words (e.g., no, mom, doggie, etc.):
 Combine words (e.g., me go, daddy shoe, etc.):
 Name simple objects (e.g., dog, car, tree, etc.):
 Use simple questions (e.g., Where’s the doggie?,etc.):
 Engage in conversation:
 Physical Deformities:
 Family History:
 Family Tree:

 Consanguinity in parents: Absent/Present

 Background history of the family:
FATHER MOTHER SIBLINGS
AGE
LIVING/DECEASED
EDUCATION
OCCUPATION

 Family history of psychiatric illness /Mental Retardation/substance

Dependence/Epilepsy:
 Family Interaction Pattern:
 Communication:
 Leadership:
 Decision-making:
 Family Rituals:
 Cohesiveness:
 Role:
 Family Burden:
 Expressed emotion:
 Educational History:
 Age of school admission:
 Highest grade completed:
 Academic performance:
 Reason for discontinuation:
 Peer relationships:
 Relationship with teachers:
 Any disciplinary problems:
 If there is any special school or classes:

 Leisure/ Play Activity:

 Hobbies & Interests:

 Discipline at home:

 Present style of living:

 Legal history:

 General Temperament and Character:

 Rationale for counselling:

BEHAVIOURAL OBSERVATION

 Consciousness: Fully Conscious/ Partial/ Absent

 General Appearance:

 Appearance:
 Touch with the surroundings:
 Eye Contact:
 Hair:
 Rapport: Easily established/ Established with difficulty/ Not
possible
 Any other observation:

 Psychomotor Activity:

 Attitude:
 Speech:
 Intensity/Tone:
 Reaction Time:
 Speed
 Prosody/ Tempo:
 Ease of Speech:
 Relevant/ Irrelevant:
 Coherent/ Incoherent:
 Goal-direction:
 Any other observation:

 Volition:

 Cognitive Functions:
 Attention and Concentration:
1. Easily aroused and sustained
2. Easy to arouse but not sustained
3. Difficulty to arouse and sustained
4. Difficulty to arouse but sustained

 Orientation:
1. Time:
2. Place:
3. Person:
4. Situation:
5. Sense of passage of time:
 Memory:
 Can the client remember: -
1. Why he/she is with you? (Immediate):
2. What he/she had for breakfast? (Recent):
3. What he/she was doing around this time last year? (Remote):
4. Are they able to recall recent events (memory and simple tasks
e.g., calculation)?:

 Abstract Ability:
 1. Concrete
2. Functional
3. Conceptual
4. Over Abstraction
 General Intelligence:
1. General Information
2. Calculation
3. Intelligence
4. Comprehension
5. Vocabulary
 Mood & Affect:
1. Subjective:
2. Objective: Euthymic/ Anxious/
Panicky/ Fearful/ Depressed/ Elated/
La- belle indifference/ blunted/ Flat
3. Depth: Normal/ Shallow
4. Range: Adequate/ Restricted

 Thought Process:
1. Associations:
2. Coherence:
3. Logic:
4. Stream:
5. Clang associations:
6. Perseveration:
7. Neologism:
8. Blocking:
9. Attention:

 Thought Content:
1. Delusional thoughts (e.g., bizarre, grandiose, persecutory, self-referential)
:

2. Preoccupations (paranoid/depressive/anxious/obsessional thoughts;

overvalued ideas).
 3. Thoughts of harm to the self or others:

4. Does the client believe that his/her thoughts are being broadcast to others
or that someone/thing is disrupting or inserting his/her own thoughts?:

 Perception:
1. Does the client report auditory, visual, olfactory or somatic
hallucinations? Illusions?

2. Are they likely to act on these hallucinations?

3. Do you observe the client responding to unheard sounds/voices/unseen

people/ objects?

4. Any other perceptual disturbances (e.g., derealisation, depersonalisation,

heightened/ dulled perception)?

 Three wishes and animal test:

 Insight:
1. How aware is the client of what others consider to be his/her current
difficulty?

2. Is the client aware of any symptoms that appear weird/bizarre or strange?

3. Is the client able to make judgments about his/her situation?

4. Child’s version of problem:

Details:
 Assignment by Peace Live Laugh.
 Assignment done by:
 Ahana Lahiri, University of Hyderabad.
 Susmita Dey, West Bengal State University.