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Case Study

This document contains a case study with sections on general information, present complaints, family history, medical history, general skills, and home environment of an individual. The individual's name, age, education, family, medical history during pregnancy and birth are documented. Test results are presented on the individual's motor skills, social skills, communication, interests, and a psychological assessment. The final section discusses the individual's home environment and family involvement in personal, educational, and leisure activities. A management plan is proposed.

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Yukti
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63 views7 pages

Case Study

This document contains a case study with sections on general information, present complaints, family history, medical history, general skills, and home environment of an individual. The individual's name, age, education, family, medical history during pregnancy and birth are documented. Test results are presented on the individual's motor skills, social skills, communication, interests, and a psychological assessment. The final section discusses the individual's home environment and family involvement in personal, educational, and leisure activities. A management plan is proposed.

Uploaded by

Yukti
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CASE STUDY

SECTION-I GENERAL INFORMATION

Date : ………………..

 Name: ………………………..

 DOB ष : ……………..

 Age (Year): …………

 Sex: ………….

 Education: ………….

 Referred by: ……………

 Language Spoken: ………….

 History Taken By: …………...

 Present
Address………………………………………………………………

 Contact no.

 Family Income(Per Month) Rs.

 Locality *: (1) Urban (2) Rural


SECTION-II

Present Complaints
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………

Onset:
…………………………………………………………………………………
………..

Previous Consultations-Yes/No (If 'Yes' specify)


……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………

SECTION-III (FAMILY HISTORY)

1) Type of Family * :…………………..

2) Marital Status*:………………….

3)Father Name*:…………………….

 Age *:……………………
 Father's Educational Qualification *:……………………….
 Father's business *:…………………………
 D. Father's monthly income (in Rs.)*:……………………..
4) Mother name*:…………………………….
 A Age*:……………………………….
 B Mother Educational Qualification*:………………………………
 C Mother business*:…………………………

 D Mother monthly income (in Rs.)*:……………………….

Household Composition/(Family and Care Taker)/

Family History of case *:


…………………………………………………………………………………
…………………………………………………………………………………
………………………………………………………………….

Relationship of the above to case


…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
……………………………

SECTION-IV (MEDICAL HISTORY)

Prenatal

 Thyriod *
 Rh-Factor *
 Miscarriage/Abortion/Still Birth
 Trauma* Yes /No
 Hypertension* Yes /No
 Drugs (If Taken)* Yes /No
 Bleeding* Yes /No
 Smoking* Yes /No
 Drinking * Yes /No
 Any Other Information:
………………………………………………………………..
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
…………………………………………………………………………….
Natal
 Delivery
Full Term 2) Premature
 Delivery Conducted By
 Delivery At
 Birth Cry Yes /No
 Color Of Baby
 Any Other Information
……………………………………………………………
………………………………………………………………………………
…………………………………

Post natal
 Thyriod

 Trauma

 Convulsion

 History Of Illness

 Test conducted (with results)


SECTION-V GENERAL SKILLS

Motor skills

Self help skills

Social skills

Attention and concentration

Communication:
 Receptive
 Expressive

Interests

Recreational activity
Status at work/school

Psychological Assessment
Test conducted
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………

Results
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………

SECTION-VI

Home Environment

Family Involvement in:


 Personal needs

 Educational or occupational needs


 Play and Leisure Activities

Management Plan

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