Advitiya Rehabilitation and learning CenteR

Email: [email protected], Ph: 9205370640, 8587855954

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Case History Record

Date: _______
Registration No.: _______

1. Demographic Data (Child)

Name Informant
Sex ☐ Male ☐ Female Language
Education Referred by
Occupation
Caste/Religion

2. Demographic Data (Parents/Guardians)

 Father’s Name:
 Father’s Education:
 Father’s Occupation:
 Mother’s Name:
 Mother’s Education:
 Mother’s Occupation:
 Present Address:

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 Permanent Address

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 Mobile :____________________Telephone: ______________________

Advitiya Rehabilitation and learning CenteR
Email: [email protected], Ph: 9205370640, 8587855954
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3. Chief/Presenting Complaints

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4. Childhood History

Prenatal History
Antenatal Checkups:-
Pregnancy ☐ Wanted ☐ Unwanted
Abortion ☐ Attempted ☐ Threatened ☐ Nil

Mother’s Age at Conception:- Father’s Age at Conception:-

Physical Built:-
☐ RH Incompatibility ☐ Diabetes ☐ Jaundice ☐ STD ☐ HIV
Mother’s Physical Health
☐ Infection ☐ Nil
Drugs During Pregnancy ☐ 1st Trimester ☐ 2nd Trimester ☐ 3rd Trimester ☐ Nil
Alcohol ☐ Yes ☐ No
Accident ☐ Yes ☐ No
Hypertension ☐ Yes ☐ No
Radiation Exposure ☐ Yes ☐ No

Nutritional Status of Mother:-

Fetal Movement ☐ Normal ☐ Sluggish ☐ Excessive
Mother’s Mental Health:-
Advitiya Rehabilitation and learning CenteR
Email: [email protected], Ph: 9205370640, 8587855954
_____________________________________________________________________________________
Natal History

Delivery Place ☐ Home ☐ Hospital ☐ Other

Term ☐ Full ☐ Premature ☐ Postmature
Labour Duration ☐ Normal ☐ Prolonged
Type of Delivery ☐ Normal ☐ Instrumental ☐ Caesarean
Abnormal Presentation ☐ Prolapsed Cord ☐ Breech ☐ Cord Around Neck ☐ Other
Excessive Bleeding ☐ Yes ☐ No
Birth Cry ☐ Immediate ☐ Delayed
Baby’s Color ☐ Pink ☐ Yellow ☐ Blue ☐ Pale
Birth Weight ☐ Normal ☐ High ☐ Low
Respiratory Distress ☐ Oxygen Given ☐ Resuscitated ☐ Incubated ☐ None
APGAR Score
Congenital Anomalies

Any Other information:-

Postnatal History

Feeding History ☐ Breastfed ☐ Bottle-fed

Feeding Time ☐ Demand Feeding ☐ Schedule Feeding
Bowel Movement ☐ Normal ☐ Frequent ☐ Constipated

Physical Illnesses
☐ Diarrhea ☐ Measles ☐ Nil
☐ Chickenpox ☐ Mumps ☐ Others:-
☐ Polio ☐ Meningitis
☐ Encephalitis ☐ High Fever
☐ Head Injury ☐ Accident
☐ Fits/Seizures ☐ Nutritional Deficiency
☐ Jaundice ☐ Infection
Advitiya Rehabilitation and learning CenteR
Email: [email protected], Ph: 9205370640, 8587855954
_____________________________________________________________________________________

Immunization History

Vaccine Primary Booster

BCG ☐ Yes ☐ No ☐ Yes ☐ No
Polio ☐ Yes ☐ No ☐ Yes ☐ No
Measles ☐ Yes ☐ No ☐ Yes ☐ No
Triple Antigen (DPT) ☐ Yes ☐ No ☐ Yes ☐ No
Hepatitis B ☐ Yes ☐ No ☐ Yes ☐ No

Menarche __________________________________

5. Family History

Type of Family ☐ Nuclear ☐ Joint ☐ Extended ☐ Broken Other

☐ Present ☐ Absent If present:- 1st cousin/2nd
Consanguinity
cousin/Other
Interpretational Relationship of family members with the child:-

a) Father’s Relationship with Child ☐ Good ☐ Fair ☐ Poor ☐ Unkown

b) Mother’s Relationship with Child ☐ Good ☐ Fair ☐ Poor ☐ Unkown
c) Siblings’ Relationship with Child ☐ Good ☐ Fair ☐ Poor ☐ Unkown
d) Grandparents’ Relationship with
☐ Good ☐ Fair ☐ Poor ☐Unknown
Child
e) Significant Other:-

Child Rearing Practices

a) Mother: ☐ Permissive ☐ Authoritarian ☐ Protective ☐ Negligent

b) Father: ☐ Permissive ☐ Authoritarian ☐ Protective ☐ Negligent

General Atmosphere at Home:-

Relationship among various family members :- ☐ Serene ☐ Quarrelsome ☐ Irritable ☐ Over Anxious
☐ Easy Going
Advitiya Rehabilitation and learning CenteR
Email: [email protected], Ph: 9205370640, 8587855954
_____________________________________________________________________________________
Family Involvement

Personal Needs of the Child ☐ Yes ☐ No

Educational Activities ☐ Yes ☐ No
Play and Leisure Activities ☐ Yes ☐ No
Support of Extended Family
- Financial ☐ Yes ☐ No
- Emotional ☐ Yes ☐ No
- Other (Specify) ________________________________

Attitude Toward the Child

Parents ________________________________
Family Members ________________________________
Neighborhood ________________________________
Siblings ________________________________

Family History of:-

Disabilities/Mental Retardation ________________________________

Mental Illness ________________________________

6.Pedigree chart
Advitiya Rehabilitation and learning CenteR
Email: [email protected], Ph: 9205370640, 8587855954
_____________________________________________________________________________________

7. Developmental History

Milestone Age Attained

a) Neck Holding _______ (2-6 months)
b) Sitting _______ (5-10 months)
c) Walking _______ (9-14 months)
d) First Word _______ (7-12 months)
e) Two-word Phrases _______ (16-30 months)
f) Sentences _______ (3-4 years)
g) Toilet Control _______ (3-4 years)

Other Developmental Concerns

h) Monetary Transaction ☐ Yes ☐ No

i) Avoid Simple Hazards ☐ Yes ☐ No
j) Scholastic Backwardness ☐ Yes ☐ No
k) Physical Deformity ☐ Yes ☐ No
l) Sensory Impairment ☐ Yes ☐ No
m) Fits ☐ Yes ☐ No

7. School History

Admitted in School ☐ Yes ☐ No

Name of the School __________________________________
Status ☐ Attended ☐ Dropped ☐ Discontinued
Advitiya Rehabilitation and learning CenteR
Email: [email protected], Ph: 9205370640, 8587855954
_____________________________________________________________________________________
Age of Joining __________________________________
Medium of Instruction __________________________________
Nature of School ☐ Normal ☐ Special ☐ Integrated ☐ Others
Attendance ☐ Regular ☐ Irregular
Duration at School __________________________________
If Irregular, Reason ☐ Does Not Go ☐ Wanders ☐ Fearful ☐ Financial Problem ☐ Others
Changes in School
Name of School Duration Reason for Change
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Classroom Behavior

Attentiveness ☐ Attentive ☐ Not Attentive

Obedience ☐ Obedient ☐ Defiant
Relation Adjustment with:-

Peer Group ☐ Favorable ☐ Unfavorable ☐ Not Known

Teachers ☐ Favorable ☐ Unfavorable ☐ Not Known

Likes/Dislikes for Subjects

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Advitiya Rehabilitation and learning CenteR
Email: [email protected], Ph: 9205370640, 8587855954
_____________________________________________________________________________________
Scholastic Performance :- ☐ Good ☐ Fair ☐ Poor ☐ Not Known

Any other information:-

8. Play Behavior

Play Interest ☐ Enjoys Play ☐ Not Interested ☐ Other

☐ Alone ☐ With Younger ☐ Peer Group ☐ With Animals ☐
Play Preference
Other
Type of Play Preference ☐ Indoor ☐ Outdoor
☐ Follower ☐ Leader ☐ Active ☐ Passive
Behavior in Play Situations

Kind of Play

a) Free Muscular Play ☐ Running ☐ Jumping ☐ Climbing ☐ Other:-

b) Experimental & ☐ Balancing ☐ Using Scissors ☐ Clay/Sand Play ☐
Manipulative Other:-
☐ Knocking Down Buildings ☐ Damaging Toys ☐
c) Destructive
Other:-
☐ Making Houses ☐ Modeling ☐ Painting/Drawing ☐
d) Constructive
Other:-

Knowledge of Games with Rules ☐ Yes ☐ No ☐ Not Known

Leisure Activities/Hobbies
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Likes/Dislikes
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Advitiya Rehabilitation and learning CenteR
Email: [email protected], Ph: 9205370640, 8587855954
_____________________________________________________________________________________
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Reasons for Poor Play Behavior

 No Companion ☐
 Siblings Uninterested ☐
 Over-Protection ☐
 Poor Play Facilities ☐
 Quarrelsome ☐
 Unwilling to Share/Take Turns ☐
 Inability to Assert Rights ☐

9. Personal History

Diet ☐ Vegetarian ☐ Non-vegetarian ☐ Mixed

Habits ☐ Tobacco ☐ Drugs ☐ Alcohol ☐ None
Bowel Habits ☐ Regular ☐ Irregular
Micturition ☐ Normal ☐ Irregular ☐ Nocturnal Enuresis
Physical Work ☐ Done ☐ Not Done
History of Allergy:-

General comments/ Any other information:-

Advitiya Rehabilitation and learning CenteR
Email: [email protected], Ph: 9205370640, 8587855954
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