CASE RECORD

IDENTIFICATION DATA:

1. Name :
2. Date of Birth :
3. Age :
4. Sex :
5. Education :
6. Status of the client : Married / Single / Divorced / Widowed
Student/ worker/ employed/ idle

DEMOGRAPHIC DATA:

7. Fathers Name :
8. Fathers Occupation :
9. Mothers Name :
10. Mothers Occupation :
11. Guardians Name :
12. Relationship to Child :
13. Guardians Occupation :
14. Education of Parents/Guardian :
15. Total Income of the family per month:
16. Socio-Economic Status of the family
a. Number of members earning :
b. Economic Status : Lower / Middle / Upper
c. Health & hygiene :
d. Socialization : Social / self isolated / ignored

17. Permanent Address :

18. Present Address :

19. Locality :
20. Religion :
21. Caste :
22. Mother Tongue :
23. Language spoken at Home :


GENERAL HISTORY OF DISABILITY


24. Type of Disability :

25. Percentage :

26. Age of onset : Congenital / Acquired

27. Age at which problem was identified:

28. Previous consultations & treatment:
(If any, specify)

29. Present Complaints :

30. Family history of Disability :

a) Mental Retardation :
b) Mental Illness :
c) Epilepsy :
d) Hearing Impairment :
e) Visual Impairment :
f) ADHD/Autism/LD/DB :
g) Multi Handicap :

h) Others Specify :

31. In the case of persons with locomotor disability, access to :
The house / rooms Yes No
The bathroom / toilet Yes No

FAMILY AND SOCIAL ENVIRONMENT

32. Pedigree chart :









33. Household Composition :

S.No. Name Relationship
to the case
Age Education Income




















34. Family Structure : 1. Nuclear 2. Joint 3. Extended 4. Uni-parent 5. Broken
35. Size: 1. Large 2. Medium 3. Small
36. No. of family members: Adults ________ Children ______
37. Neighborhood Interaction : Normal / Fair / Poor



GENERAL EMOTIONAL CLIMATE IN THE FAMILY
39. Family involvement in
i) Personal needs of child : Good / Fair / Poor
ii) Educational Activities : Good / Fair / Poor
iii) Play and Leisure Activities : Good / Fair / Poor

40. Interpersonal relationships of family members with child:
i) Father :
ii) Mother :
iii) Siblings : Brother:
Sisters :
iv) Grandparents :
v) Significant others :

41. Persons with whom the child is most attached:

42. Persons with whom the child has reportedly more problems :

S.No. Presence of other problems Yes No Details
1. Sibling rivalry
2. Bullying by siblings
3. Unfair comparing by parents
4. Less time to parenting due to
their pre-occupations

5. Strained marital relationship
6. Unhelpful attitude of
neighbours

7. Any other

43.
Family
Members
4
Over
indulgence
and caring
3
Very
affectionate
and caring
2
Affectionate
1
Indifferent
0
Rejection
a) Father
b) Mother
c) Siblings 4
Very
affectionate
3
Affectionate
and Caring
2
Indifferent
1
Rejection
0
Bully and
Tease
Elders
Younger Ones
d) Others



NATAL HISTORY

Consanguinity : Yes / No
Age of conception

PRENATAL HISTORY
Attempted abortion :
Rh Incompatibility :
Diabetes
Inadequate Nutrition :
Trauma :
Jaundice :
Drugs (Specify the Trimester) :
Alcohol :
Others :
PERINATAL HISTORY
Delivery place :
Term :
Labour Duration : Normal / Prolonged
Labour Induction :
Delivery Type : Normal / Caesarian / Instrumental / Others
Abnormal Presentations :
Prolapsed Cord :
Cord around the neck :
Feeding Problem :
Convulsions :
Accident :

Malnutrition :

Acute emotional stress or shock :

Unwanted pregnancy

Excessive medication, drugs, alcoholism:

Birth weight : Normal / Low / High
Colour of the Baby :

Birth Cry :

Multiple Pregnancies :

Others


POSTNATAL HISTORY
Infections :
Jaundice :
Convulsions :
Injury :
Nutrition Disorders :
Immunization :

Previous Training :

I MMUNI SATI ON HI STORY
Polio : Not Partially Fully
Diptheria :
Pertusis :
Tetanus :
Measles :
DEVELOPMENTAL HI STORY( for those applicable)
a. Motor Milestones
Head control (1-4 m) : Normal Delayed
Sitting (5-10 m) :
Standing (12-18 m) :
Walking (16-30 m) :
b. Speech and Language
Vocalization
Babbling (6-8 m) :
First Word (7-12 m) :
Two Word Phrases (30-36 m) :
Sentences (3-4 yrs) :
c. Adaptive
Avoiding Common Dangers :
Writing few alphabets :
d. Personal / Social
Smiles at others :
Responds to Name :
Feeds Self :
Dresses Self :
Toilet Control :



EDUCATI ONAL HI STORY
Name of the School :
Type of the School :
Class :
Duration of Schooling :
Attendance :
Previous work / Training experience : years
The kind of work / Training experience :

Place of work / Training :

OBSERVATI ONS
a. Learning
Enthusiasm in the class :
Contributing in the class :
Relationship with peers :
Test Performance :
Attention and memory :
Relationship with the teacher :
Performance in the assigned work :
b. Work environment
Relationship with staff
Relationship with peers :
Liking towards the work :
Working capacity :
Future plans :
Performance
c. Institutional Activities
(Extra Curricular) Specify
Initiative :
Involvement :
Participation in Extra Curricular
Activities :
d. Hostel environment
Interpersonal Relationship :
Helping Tendency :
Problem Solving :
Co-operation :
Friendships :
Emotional Being (Mental Health) :
e. Social Environment
As perceived by the family :
Expectations :
GENERAL
Health and Hygiene :
Discipline and Orderliness :
PLAY
Play Behaviour :
(a) Enjoys Play :
(b) Not Interested :
(c) Observe others playing :
Reasons for Poor Play Behaviour
1. No Companions :
2. Peer group avoids playing :
3. Quarrelsome :
4. Over Protection :
5. Poor play facilities :
6. Others (Specify) :
7. Leisure time Activities :
SEXUAL HISTORY
1. Attained Menarche :
2. Secondary Sexual Characteristics :
PHYSICAL EXAMINATION ( for those applicable)
Head :
Eyes :
Ears :
Nose :
Hair :
Skin :
Vision :
Audition :
Speech :
Limbs :
Left Hand :
Left Leg :
Right Hand :
Right Leg :

COGNTIVE SKILLS
1. Attention : Good / Bad / Fair
Following Simple Instruction : Yes / No
Awareness of danger & Hazards : Yes / No
2. Concept Formation ( , x )
Colour : Size : Sex : Shape :
Time : Numbers : Money :

3. Academic Skills (Good, Average, Poor)







Reading :
Writing :
Arithmetic :
4. Awareness of danger & hazards ( for only mentally retarded )

Concept Formation

a) Colour
i) Knows basic colours
ii) Knows secondary colours
iii) Not aware of colours



b) Size
i) Knows big and small
ii) Knows long and short
iii) Knows tall and short

c) Sex
i) Knows both sexes
ii) Able to discriminate

d) Numbers
i) Knows 1 to 20
ii) Able to associate the numbers and value
iii) Able to write till 20

e) Time
i) Knows day and night
ii) Knows an hour
iii) Knows minutes

f) Money
i) Knows 5 Np, 10Np, 25 Np, 50Np, 1 Rupee
ii) Knows 2 Rs., 5 Rs., 10 Rs.

BEHAVIOURAL HISTORY
Mood :
Normal :
Bated :
Depressed :
Frustrated :
Imitable :
Destructive :
Odd Behavior :
Withdrawn Behavior :
Hyperactive Behavior :

THERAPIES & RECOMMENDATIONS
Behaviour Modification :
Yoga Therapy :
Any other :

Date : Recorded and reported by :