Government girls degree college no 2, Haripur, KPK ,

Pakistan

DEMOGRAPHIC SHEET
Name ___________________ Age __________________

Gender __________________ Education _____________

Marital status _____________ Religion _______________

Sibling ___________________ birth order _____________

Father name_______________ Age ____________________

Occupation ________________ Education _______________

Deceived or alive ___________

Mother name ______________ Age _____________________

Deceived or alive ___________ Education ________________

Case No _________________

Father name ______________

Intake by ________________

Date of intake _____________

1. REASON FOR SOURCE OF REFERRAL

2. PRESENTING PROBLEMS
As presented by client
Duration presenting complaints
3. HISTORY OF PROBLEMS OR ILLNESS( duration of present problems, change in nature frequency
of problems over time, other past problems of psychological nature, no of attacks)
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4. FAMILY HISTORY ( parents and sibling relationships (healthy or unhealthy), general atmosphere,
psychiatric AND physical illness, deaths, drugs)
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5. PERSONAL HISTORY ( birth ( pre or post injury )
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a. SCHOOL HISTORY (marks, divisions obtain , school changes, school problems, relationship with
peers and teachers, extracurricular activities)
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b. OCCUPATIONAL HISTORY ( nature of job, salary, time duration, environment, relationship with
junior, colleagues and boss)
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c. HISTORY OF FRIENDSHIP (nature and extend of relationships, recreation degree of religiosity ,
sexual history, premarital , marital sexuality)
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d. MARITAL HISTORY (duration of marriage, relationship with spouse, occupation, income, nmber
of children)
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e. DRUG HISTORY
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6. PAST PSYCHIATRIC HISTORY/ TREATMENT ( non psychiatric patient ( if yes), episode , reason,
duration, details of treatment sought for presenting problems when and for what duration
treatment undergone, nature of treatment method, drugs taken, ECT’S , faith of healing,
response to treatment, including adverse and/or side effects)
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7. MEDICAL HISTORY ( most recent physical exam, dates and results, current medications, addition
since childhood, including details of serious illness/ disability suffered )
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8. ADDITIONAL INFORMATION
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9. PRE-MORBID PERSONALITY
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10. MENTAL STATE EXAMINATION
Appearance / behavior (restless, anxious, confused, reserved, conscious, oblige, alert)
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Personal hygiene (nail, hair, combing, neatness, dress iron)
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Speech/ gesture/ posture/ movement ( speech- mute, talkative, abusive, motor restless,
assaultive, destructive, excited, retardation, unusual gesture, preservative movements)
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Mood (congruent, incongruent, flat effect, sad, depressive, irritable)
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Depersonalization/ derealiztion/ obsession/ delusion/ hallucination
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Orientation ( person, place and time)
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Attention, concentration
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Memory (current, motor, remote)
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Insight
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Judgmental ability
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Abstract thinking
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Formal assessment (scale, scoring)
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Tentative diagnosis
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Case formulation (perspective)
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Recommendations
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