DEPARTMENT OF CHILD &ADOLESCENT PSYCHIATRY

NIMHANS, BANGALORE
Child and Adolescent Psychiatry Evaluation Proforma
Name:

Age:

Sex:

Educational status:

Case worked up by:

Trainee Status:

Date of work-up

Source and reason for referral:

Informants:

Reliability and Adequacy of History:

Reliable/Unreliable
Adequate/ Inadequate
(Please note reasons for considering history unreliable/inadequate)

Chronological list of complaints with duration

Main reason for consultation:

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Family History:

Genogram/Family Tree

(preferably three generation with use of internationally accepted symbols, depicted below, and
indicating abortions, perinatal deaths , twins, affected members etc)

Family history of illness: (Neurodevelopmental disorders, other handicap, epilepsy, psychiatric illness,
substance use disorders, neurological illness, early death, suicidal attempts, completed suicide)

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Consanguinity among parents: [Father married to: Sister's daughter, Mother's brother's daughter,
Father's sister's daughter, father's brother's daughter (Encircle the appropriate), If any other – please
specify]

Descriptive account of parents / significant others / other family members if relevant including age,
education, occupation and any other relevant details
Father:
Mother:
Siblings:
Others:

Family life and relationships (include family setup & environment, living conditions and current living
arrangements, cohesiveness, parental relationships, emotional atmosphere, parent – child relationships,
relationship with siblings, communication style in the family, child rearing practices, daily life pattern,
stress in family, including family’s understanding of the illness, and treatment expectations etc)

Personal History

Pre-natal factors: (State of mother during pregnancy) (Tick and describe) (Nutritional Deficiencies,
teratogen Exposure, Infections (measles etc), Fever, antepartum bleeding, Rh incompatibility, maternal
stress, maternal diseases (hypertension, diabetes, pre-ecclampsia, toxemia, hypothyroidism, psychiatric
illness, etc), any other)

Perinatal Factors (including Neonatal)

Labour: Normal/abnormal (if abnormal, tick and describe)
Premature, Post-mature Prolonged labour, Foetal distress, Assisted labour, Abnormal presentation,
placenta praevia, Induced labour, Cord round the neck, caesarian section, any other

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Child at birth:
Birth weight: HC:
Cry-normal, delayed/no cry,
Congenital anomalies (including small head),
Others: (tick and describe) Apneic spells, Cyanosis (APGAR Score if available), Jaundice, need for
resuscitation.

First four weeks (tick and describe): (Respiratory distress, Excessive crying, Cyanotic attacks, Feeding
problem, Jaundice, High fever, Fits, altered sensorium,. Hypoglycaemia, Hypocalcamia, Fever, Incubator
care, any other)

Immunization History:

If not up to date:
Importance of Immunization explained: YES / NO: Pediatrician referral made: YES / NO

Developmental History
Delay present /absent
If present, Delay first noticed at ______ age

Developmental course: typical / gross delay from birth / mild delay from birth / only specific delay / loss
of acquired milestones (regression)/ regression in background of delay / other

Current level of development, including mother's estimation of mental age:

Developmental milestones
Motor Cognitive
Head Control 3months Visual tracking 3 months
Sits without support 7months Reaches for objects 5months
Independent Walking 15 months Pincer grasp 1yr
Runs well 2yrs Scribbles 18 months
Rides tricycle 3 yrs Remembers hidden objects 2yrs
Catches tossed ball 4 yrs Draws circle 3yrs
Skips 5 yrs Writes /recognizes few alphabets 4yrs
Names a few colors
Social Speech / language
Social smile 3months Babbling(ba-ba etc) 8months
Recognizes mother 5months 2 meaningful words 15months
Imitates (Tata, Namaste, clap-clap) 1yr Identifies few body parts 18months
Points to objects on request 18 months Follows 2-step commands 2yrs
Pretend play 2 yrs 2 word phrases 2yrs
Cooperative play 3yrs 3 word sentences 3yrs
Dress self without help 4yrs Asks questions 4yrs
Fully toilet trained 5yrs

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Temperament and personality traits: (Give an account based on child’s sociability, emotionality (general
mood, affect regulation), attention / concentration, activity level, impulsivity, adaptability, others); also
record any temperamental risk factors such as stubbornness, sensitivity to criticism, moodiness,
excessive shyness, aggressive tendency etc.)

Schooling: (Age at admission to school, type of school – regular/special, academic performance,

participation in extra-curricular activities, change of schools/boards (CBSE,ICSE,IGCSE,IB etc.), reason for
change of school, highest class achieved, difficulties in school including academic difficulties, bullying
experiences, and if not attending school, mention duration of absenteeism and child’s routine in brief)

Menstrual and sexual history:

Hobbies, interests, talents, strengths:

Past History (Significant medical / psychiatric problems prior to the onset of present illness including
medication and treatment that the child may have received till date including interventions received and
if any improvement was perceived with those interventions)

History of presenting illness: (Describe onset, ppt factors, maintaining factors, stressors, chronological
evolution of symptoms, current problems, treatment history till date (including screening details at
NIMHANS), negative history, family perception and responses to the problem and graphic charting of
illness over lifetime if needed. Use extra sheet if needed)

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Psychiatric Examination: Note the following: comfort level during examination, cooperativeness,
rapport, social responsiveness, Speech and language skills, alertness, attention and concentration,
activity level, mood and affect (subjective and objective), thought processes (stream, form, content,
control), perception, general intelligence, child's version of the problem, 3 wish test, insight). If a non-
verbal child or with neurodevelopmental issues also note externalizing (hyperactivity, inattentiveness,
impulsivity, tantrums etc), internalizing (crying / clinging, irritability, anxiety, compulsions etc), features
of ASD ( poor eye contact, poor response to name call, stereotypies etc.), autistic, self-injurious
behavior, mood changes, recent onset behavior change, sleep /appetite changes, psychotic symptoms,
others)

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Physical examination: (under each item, some common anomalies are listed: screen the child for these,
or any other abnormalities and mention).

Ht (with comments):
Wt (with comments):
HC:
BMI:
Birth mark / Identification mark:
1.
2.

Facial appearance (Mongoloid, gorgoylism, round, elongated)

Shape of head: (Micro, Macro, dolicho, oxycephaly)
Skin: (Abnormal colour and thickness, pigmentation, naevi, café-au-spots, tuber, eczema, ichthyosis)
Hair : (light or grey coloured, sparse, excessive body hair, kindly, brittle)
Vision: (diminished, absent, night blindness, refractive error)
Eyes: (bushy eyebrows, eyebrows meeting in centre, slanting of palpebral fissure, epicantic folds, hypertelorism,
micro cornea, corneal clouding, corneal opacities, cataract, nystagmus, squint, blue sclera, any other)
Hearing: (Partial or total deafness)
Ears (low set, posterior, simplified, malformed, lopears, long ears)
Nose: (Short, depressed bridge, flaring, beak shaped)
Oral cavity: (Look for cleft lip and palate, high arched palate, malformed dentition, fissured tongue etc).
Other facial features: (long forehead, long philtrum fullness in sub-mental region )
Limbs: Short, long, asymmetric, increased carrying angle)
Hands and feet: (Simian crease, Sydney line, poly or syndatyly flat feet, webbing,
little finger, anomalies describe)
Chest: (including heart and respiratory systems (Pigeon chest, murmurs, pectus excavatum, pectus carinatum,
gynaecomastia, displaced nipple etc)
Abdomen: (Distended, umbilical, or inguinal hernia, hepatospenomegaly)
Neck and spine: (webbing, short neck, kyphoscoliosis, post-anal dimple, spine bifida, gibbus)
External genitalia: (Hypogenitalism, Hypospadias, undescended testis, large testis)
Secondary sexual characters:
Skeletal anomalies
Neurological (Specially look for hypotonia, cerebral palsy, movement disorders, gait disturbances, ataxia), Posture,
Bulk, Power, Tone, Reflexes, co-ordination, involuntary movements, pupils, extra-ocular movements,
fundal examination

Sum up the important physical examination findings, including Syndromal diagnosis if any: Down /
Fragile X/ Cornelia de Lange/ Cockayne / Prader-willi / Laurence Moon BB/ Others)

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Tasks given to the child (please attach)

Brief ABC analysis of problem behaviours, if any, in the past month

Antecedent Behaviour Consequence

Rating scales as applicable with scores and interpretation

Assessment of functionality and illness severity

CGAS rating:
Rate the child’s most impaired level of general functioning over the last one month by selecting the lowest level which describes his/her
functioning on a hypothetical continuum of health-illness. You could use intermediary levels (e.g. 35, 82). Rate actual functioning regardless of
treatment or prognosis.
91-100 Superior functioning in all areas
81-90 Good functioning in all areas
71-80 No more than slight impairment in functioning
61-70 Some difficulty in a single area, but generally functioning pretty well
51-60 Variable functioning, sporadic difficulties/symptoms in several (not all) social areas
41-50 Moderate degree of interference in functioning in most social areas/severe impairment in one area
31-40 Major impairment in functioning in several areas and unable to function in one of these areas
21-30 Unable to function in almost all areas
11-20 Needs considerable supervision to prevent hurting others or self/ maintain hygiene/ communication
1-10 Needs constant supervision (24-hour care)

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CGI Illness severity rating:
Considering your total clinical experience with this particular population, how mentally ill is the child at this time?
0 1 2 3 4 5 6 7
Not assessed Normal Borderline ill Mildly ill Moderately ill Markedly ill Severely ill Extremely ill

Psychometric reports (include assessment results from previous testing elsewhere):

Record, date/age of child at testing, and where the tests were done.

IQ assessment:

Assessment for SLD:

Any other developmental/psychometric assessment done:

Diagnostic formulation:

Rutter’s Multiaxial Diagnosis

Before Discussion After Discussion

Axis 1 Axis 1

Axis 2 Axis 2

Axis 3 Axis 3

Axis 4 Axis 4

Axis 5 Axis 5

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Discussed with:
Discussion notes, including management & follow-up plan

Signature with name, designation and date:

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