CASE HISTORY RECORD

1. Name:_____________________________________________________________________________
2. Age:__________________________________
3. Sex:__________________________________
4. Occupation:_______________________________________________________________________
5. Residence :Urban/Rural
6. Address:___________________________________________________________________________
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7. Marital Status: Married/Unmarried/Single/Separated/Divorce
8. Mother Tongue:____________________________________________________________________
9. Religion:_________________________________________________________________________
10. Family Type: Nuclear / Joint
11. Socio-economic-status: Lower / Middle /Upper
12. No of family members:___________________________________________________________
13. Source of reference:_____________________________________________________________
14. Reason for referral:_____________________________________________________________
________________________________________________________________________________
15. Informant’s name:__________________________________________________________________
16. Relationship with client:____________________________________________________________
17. Duration of relationship with client:_____________________________________________________

18. Reliability and adequacy:

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19. Present Complaints:
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 20.Duration of Present complaints:
__________________________________________________________________________________
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21. History of present illness:
I. Mode of onset:
• Abrupt sudden(within 48 hours):________________________________________
• Acute(within 2 weeks):_______________________________________________
• Insidious(More than 2 weeks):_________________________________________
• Patient apparently well:______________________________________________
II. Predisposing Factor:_________________________________________________________
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Precipitating factor :
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Perpetuating factor:
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22. Course :Continuous/episodic/Fluctuating/Not Known
23. Progress: Improving/Deteriorating/Status quo
24. Biological Functions:
• Sleep:____________________________________________________________________
• Appetite:____________________________________________________________________
• Bowel and bladder movement:__________________________________________________
• Sexual Interest and activity:______________________________________________________
• Predominant Emotional State(Last 3 month):
____________________________________________________________________________
25. Negative History:
• History of deliberate self-harm:
___________________________________________________________________________
• Suspiciousness:______________________________________________________________
___________________________________________________________________________
 • Bodily pre-occupational symptoms:______________________________________________
___________________________________________________________________________
• History of fever or head injury or other medical condition:
____________________________________________________________________________
26. Treatment History:
I. Medical History:_____________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
II. Psychiatric history:____________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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27. Family history:
I. Family tree:

II. Father:
Age:__________________________________________________________________
Living/dead:____________________________________________________________
Cause of death:__________________________________________________________
Education:_____________________________________________________________
Occupation:____________________________________________________________
III. Mother:
Age:__________________________________________________________________
Living/dead:____________________________________________________________
Cause of death:_________________________________________________________
Education:_____________________________________________________________
Occupation:____________________________________________________________
 IV. Family Interaction pattern:
• Communication:_______________________________________________________________
____________________________________________________________________________
• Leadership:___________________________________________________________________
__________________________________________________________________________
• Decision making:_____________________________________________________________
____________________________________________________________________________
• Role:________________________________________________________________________
____________________________________________________________________________
• Family rituals:_______________________________________________________________
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• Cohesiveness:_________________________________________________________________
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• Family burden:_______________________________________________________________
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28. Any Psychiatric History:
• Psychiatric Illness/MR/Suicide:_________________________________________________
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• Substance abuse/Epilepsey:_____________________________________________________
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29. Personal history:
I. Birth:
• Preterm/Full term/Post term:_____________________________________
• Birth Crying:__________________________________________________
• Type of birth:____________________________________________________
• Birth complication:________________________________________________
• Milestone:________________________________________________________
________________________________________________________________
_______________________________________________________________
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II. Parents and home situation:
______________________________________________________________________
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III. Academic history:
• Schooling:_______________________________________________________
_____________________________________________________________
• Academic Performance:____________________________________________
____________________________________________________________
• Peer relationship:________________________________________________
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• Disciplinary problem:_____________________________________________
______________________________________________________________
• Hobbies and interest:_______________________________________________
________________________________________________________________
IV. Habits/Interests:_________________________________________________________
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V. Occupational history:
______________________________________________________________________
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VI. Menstrual history:
______________________________________________________________________
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VII. Sexual history:
______________________________________________________________________
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VIII. Marital History
______________________________________________________________________
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30. Premorbid Personality:
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