CASE HISTORY PROFORMA FOR

• Socio Demographic Data

• Informant Details

• Brief Clinical History

• Clinical Diagnosis

• Family History

• Brief Personal History

• Premorbid Personality

• Mental Status Examination (MSE)

• Summary

• Disability Assessment

• Resource Assessment

• Expectations (Individual level and Family level)

• Psychosocial Rehabilitation Plan ( Goals and Interventions)

SOCIO DEMOGRAPHIC DATA:

Name, Age (Years), Gender (Male/Female), Marital Status (Single, Married, Separated, Divorced, Widow,
Widower), Education (up to what standard he/she studied),
Occupation (currently working/ not working), religion, Socio Economic Status (upper/middle/lower),
Domicile (urban/rural).
INFORMANT DETAILS:
Mention here the source of information and relationship of the informant to the patient. Also mention the
reliability and adequacy of the information.
BRIEF CLINICAL HISTORY:
Give a brief and coherent account of the symptoms with duration. Describe major abnormal behavior,
associated problems like homicide/suicide and social/occupational functioning changes in daily life etc.
record here the past psychiatric treatment history which includes faith healing, pharmacotherapy, ECT,
family interventions and rehabilitative measures.
• (Substance abuse/ dependence cases)
Mode of initiation, early pattern of intake, progression, tolerance, craving, physical withdrawal
features, pattern of use in recent/past, medical complications (including accidents), neuropsychiatric
problems, interpersonal problems, socio economic problems(including debts, if any), occupational
problems, problems with law, earlier attempts to abstain, reason for consultation, motivation for
abstinence etc. (in cases of multisubstance use, describe separately for each substance).

FAMILY HISTORY:
• Genogram – family of origin
(Draw the family tree for three generations on both sides in cases of genetic importance)
• Give a description of the individual family members (parents and siblings).
The description should include information as to whether they are living or dead, age, education,
occupation, health condition and relationship with the index patient and details of their spouses.
• Enquire about history of illness in the family such as mental illness, physical illness, suicide
substance abuse, epilepsy and mental retardation.
• Describe the interaction patterns of the index family such as interaction pattern between the
parents, between the parents and children, amongst the siblings.
• Describe the family dynamics of this family which include leadership pattern, communication,
role, reinforcement, cohesiveness and social support.

BRIEF PERSONAL HISTORY:

Report on birth and early development, behavior problems during childhood, health problems during
childhood, schooling, occupational history, menstrual history, sexual history, marital history (draw a family
tree for the index patient if he or she is married).
Enquire regarding age at the time of marriage, whether arranged by elders or by self, was there mutual
consent of the partner, consanguineous or non consanguineous marriage, quality of marital relationship,
any separation or divorce, note the number of children, their age and health status and history of substance
use.
PREMORBID PERSONALITY:
Give details and cite example from patient’s past life i.e., before the onset of the illness. 1).Social relations
(To family (attachment, dependence), to friends, groups, societies, to work, to workmates). 2).Intellectual
activities (Hobbies and interests).
3). Mood (Cheerful, optimistic, pessimistic, stable, fluctuating etc). 4).Character (Attitude to work and
responsibility, Inter personal relationships, Standards in moral, religious, social, Fantasy – day dreaming –
content, frequency). 5). Habits (Alcohol consumption, Tobacco consumption, Self medication with drugs).

MENTAL STATUS EXAMINATION (MSE):

The components in the MSE are following:
• General Appearance and Behavior
• Speech
• Mood
• Thought
• Perception
• Cognitive Functions
• Insight
I GENERAL APPEARANCE AND BEHAVIOUR (GAB):
a. Appearance
i. Level of Grooming - Normal/Shabbily dressed/Over dressed
ii. Level of Cleanliness - Adequate/Inadequate/Overtly clean
iii. Level of Consciousness - Alert/Drowsy/Stuporous/Comatose
b. Cooperativeness - Normal/More then so/Less than so
c. Eye-to-Eye contact - Maintained/Difficult/Not maintained
d. Rapport - Spontaneous/Difficult/Not established
e. Psychomotor Activity - Normal/Increased/Decreased
f. Other Movements - Mannerisms/Stereotypes/Tremors/Perseveration
II SPEECH: (Spontaneous or only in response to questions)
a. Relevance - Fully relevant/Irrelevant/Sometimes off target
b. Coherence - Fully coherent/Incoherent
c. Volume (amount of speech) – Normal/Increased/Decreased
d. Tone (pitch) - Normal variation/Monotonous
e. Reaction time - Normal/Delayed
III MOOD:This should be assessed by both subjective report and objective evaluation.
Generally ask the patient – ,How are you?
a. Subjective – write the patient’s verbal response as it is.
b. Objective (assess the quality of emotion) - happiness/sadness/anxiety etc.
c. Range (affective response) - normal/ not
d. Reactivity (emotions related to environment) - normal/ not
e. Congruence - congruence/ incongruence
f. Appropriate/ inappropriate
g. Lability (any crying/ laughing spells)
IV THOUGHT: You have to ascertain the presence of various symptoms,
If present explain as it is.
1. Form:
a. Derailment - the thought slides on to a subsidiary thought.
b. Substitution - a major thought is substituted by a subsidiary thought.
c. Omission - is in senseless of thought or part of it.
d. Fusion - heterogeneous elements of thought are interwoven
e. Driveling - is a disordered intermixture of constituent parts of one’s complex thought.

2. STREAM:
a. Flight of ideas - thoughts follows each other rapidly, there is some Connectivity in thinking
-like steps in staircase (Clang association- rhyming, punning).
b. Retardation of thinking - the train of thought is slowed down and the number of ideas and
mental images which present themselves are decreased.
c. Circumstantiality - thinking proceeds slowly with many unnecessary trivial details but
finally point is reached.
d. Perseveration - the same word or phrase is used regardless of the situation.
e. Thought block - sudden arrest of the train of thought, leaving a blank. An entirely new
thought may begin.

3. POSSESSION:
a. Obsessions and Compulsions
Obsession - an obsession is an idea and this particular thought cannot
got rid of, although when the individual realizes that it
is senseless and silly, is unable to cope with it. Any
attempt to ignore it causes varying amount anxiety.
 Compulsion - compulsions are motor acts, similar to obsessions.
(obsessional impulse which leads directly to the action)
Eg: obsessional fear of contamination leads to compulsive washing.
Clinical Features – Intrusive and repetitive.
Four components – obsessional image, ideas, fears and impulses.
Image – obsessional images are vivid images which occupy the
patient’s mind.
Ideas – obsessional ideas take the forms of ruminations on all kinds
of topics.
Fears – consist of a groundless fear which the patient realizes is
dominating without cause.
Impulses – may be impulses to touch, count or arrange.
b. Thought insertion – thought are being inserted into his mind or
imposed by external forces.
c. Thought withdrawal – thought cease or thoughts are withdrawn from
his mind by a foreign influence.
d. Thought broadcast – thoughts are escaping the confines of his self and
are being experienced by others around.
4. CONTENT:
Look for presence of ideas/ over valued ideas/ delusions.
Delusion – “is a false unshakable belief, which is out of keeping with the
patient’s social and cultural background”.
You have to ascertain presence of delusions
if present explain as it is.

a. Delusion of persecution b. Delusion of love

c. Grandiose delusion d. Delusion of jealousy
e. Delusion of ill health f. Delusion of Guilt
g. Nihilistic delusion h. Delusion of poverty
i. Delusion of referance j. Delusion of infidelity

V PERCEPTION:
1. Hallucination: ( a false perception in the absence of any stimulation).
a. Auditory - Hearing voices (1st person, 2nd person, 3rd person)
 b. Visual - Scene/ Visual projection
c. Olfactory - Smell
d. Gustatory - Taste
e. Tactile - Sense of touch – eg. Crowling of ants
f. Extracampine - Outside the limits sensory fields
g.Bizarre hallucinations
h. Reflex hallucinations

2. Pseudohallucinations - are type of mental image which although clear and vivid
lack the substantiality of perceptions.

3. Illusion - a false perception in the presence of a stimulus.

VI COGNITIVE FUNCTIONS:

Clinical assessment includes the areas of

1. Orientation
2. Attention and concentration
3. Memory
4. Intelligence
5. Jugement

1. Orientation:
a. Time - Approximate time/ Day time or night/Day/Date/Month/Year
b. Place - Kind of place/Area/City
c. Person - Self/Close associates/hospital staff

2. Attention and concentration: (assess in three areas)

(i) The digit span test (forward and backward)
(ii) Serial subtraction
Days of months (forward and backward)

(i) Digit span test:

i.Forward:
5-7-3
 5-3-8-7
1-6-4-9-5
3-4-1-7-6-8
7-2-5-9-4-8-3
4-7-2-1-6-8-5-9

ii. Backward:
4-1-7
6-1-5-8
2-9-7-6-3
6-1-5-8-3-9
4-7-1-5-3-8-6
9-2-5-8-3-1-7-4

(ii) Serial Subtraction:

20-1- 20, 19, 18 etc reversed in 15 secs.
40-3- 40, 37, 34 etc in 60secs.
100-7- 100, 93, 87 etc in 120 secs.

(iii) Days or Months- forward/ backward

3. Memory:
a) Immediate – (same test for attention)
b) Recent- Recent happenings( last meal/ visitors etc)
Address test
Recall (asked after 5mts)
c) Remote- Information on life events
Date of birth
Number of children
Year of completing education
Marriage date/ death date
4. Intelligence:
a. General information- Name of prime minister
- 5 rivers/cities/states
- Capitals
 b. Comprehension - what you will do when you feel cold?
- what will you do when you miss the bus?
c. Arithmetic - I borrowed 6 rupees and returned 2 rupees, how
much do I still owe him?
d. Abstraction – tested by three measures
Similarities – Orange – Banana (fruits)
- Dog – Lion (animal)
- North – West (directions)
Differences - Cinema – Radio (audio and visual – audio only)
Proverbs - (tell the patient and ask to explain)
- Slow and steady wins the race
- Empty vessels make noise
Judgment:
a. Personal – Future plan
b. Social - Observing behavior
(what is socially and culturally accepted)
c. Test - Fire problem
Letter problem
VII. INSIGHT:
* Awareness of problems – (Physical problem or Mental problem)
* Presence or Absences or partial
CLINICAL DIAGNOSIS:
Write the clinical diagnosis according to ICD – 10.

SUMMARY:
The purpose of a summary is to provide concise description of all the important aspects of the case to
enable others who are unfamiliar with the patient to grasp the essential features of the problem. Lastly
the interviews have to write the current level of functioning of the index patient.

B. Intervention Strategies:

1) Individual level 2) Family level.

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