CASE HISTORY PROFORMA

Reg. No of the child in the school : Admission no :

Reference No : Date :

SECTION : I
Identification date :

Name of the child :

Age. :

Date of birth. :

Sex. :

Father’s name. :

Father’s occupation. :

Mother’s name. :

Mother’s occupation. :

Guardian name :

Guardian occupation. :

Guardian relationship to the child. :

Present address & phone no :

Permanent address & phone no. :

Total family income/month. :

Socio – economic status of the family : high/middle/low

Area. : Urban/rural/semi urban

Language spoken

SECTION : II
I. Informant name and relation with the case :

II. Present complaints :

( As reported by parents or informants )

III. Age at which the problem was recognized. :

 IV. Previous interventions :
( Name of interventions, duration&
Consequences to be listed in chronological order )

SECTION : III
A. PRENATAL
I. Whether gone for antenatal checkups :

II. Age of parents at conception. :

III. Exposure to X – ray : Yes/no

IV. Attempted abortion : Yes/no

V. Threatened abortion. : Yes/no

VI. Foetal movements : normal/exclusive/sluggish

VII. Drugs intake :

VIII. Any health problem during pregnancy. :

( specify )

B. NATAL
I. Full term / pre mature / post mature :

II. Delivery. : home/hospital

III. Labour. : prolonged/induced

IV. Abnormal presentation. : Breech/transverse

V. Prolapsed cord / cord around the neck. :

VI. Birth cry : immediate/delayed

VII. Jaundice. :

VIII. Infections :
IX. Birth weight. :

X. Twins. : yes/no

XI. Excessive bleeding. : yes/no

XII. Swallowing or sucking difficulty. :

XIII. Excessive crying :

C. POSTNATAL
I. Color of the baby. : pink/yellow/blue/pale

II. Respiratory distress. : Yes/no

III. Malnutrition. :

IV. Jaundice. :

V. Trauma. :

VI. Infections. :

VII. Convulsions. :

VIII. Any other. :

IX. Any significant problem after 3 months. :

D. IMMUNIZATION HISTORY

I. Not immunized/partially immunized/fully immunized

E. DEVELOPMENT MILESTONES : normal/delayed/remarks

I. Respond to name/voice ( 1 – 3 months ). :

II. Smiles at others (1 – 4 months ). :

III. Holds head study ( 2 – 6 months ). :

IV. Sits without support ( 5 – 10 months ). :

V. Stands without support ( 9 – 14 months ). :

 VI. Walk well ( 10 – 20 months ). :

VII. Talk in 2 – 3 words sentence ( 16 – 20 months ). :

VIII. Eats/drinks by self ( 2 – 3 years ). :

IX. Tell his name ( 2 – 3 years ). :

X. Has toiled control ( 3 – 4 years ). :

XI. Avoids simple hazards ( 3 – 4 years ). :

F. EMOTIONAL AND BEHAVIORAL PROBLEMS

(If any)

SECTION : IV
SCHOOL HISTIRY : ATTENDED/NOT ATTENDED/DISCONTINUED

I. Nature of school : normal/special/integrated/other

II. Attendance. : Regular/irregular

( reason for irregularity)

III. Frequency and reason for change of school. :

IV. Scholastic performance : Good/average/never failed/poor

V. Peer group adjustment. : Favorable/unfavorable

VI. Any other information. :

SECTION : V
PLAY

I. Prefers to play alone :

II. Play most of the time. :

III. Play games governed by rules. :

 IV. Indifferent/enjoys play. :

V. Play with order/younger/peer group. :

VI. Behaviour at play in group situation. :

VII. Leisure time activities. :

SECTION : VI
SEXUAL HISTORY

I. Attend menarche. : Yes/no/not applicable

II. Age. :

III. Regularity of menstrual period : Regular/irregular

IV. Ability to attend menstrual hygiene :

V. Record the abnormal sexual behaviour ( if any ):

SECTION : VII
FAMILY HISTORY

I. Pedigree chart :

II. Type of family. : Joint/nuclear/extended/broken/other

III. Consanguinity : first cousin/second cousin/other/unrelated

( If consanguinity present describe the relation in detail )

IV. Family history of mental illness, epilepsy, mental retardation and other (give details)

SECTION : VIII
SOCIAL ENVIRONMENT

I. Neighborhood interaction. :
 II. Family environment. : Supportive/not supportive

III. Participation in socio – religious activities. :

SECTION : IX
Management problem with regard to the case

SECTION : X
Misconceptions

SECTION : XI
Expectations

SECTION : XII
Management plan