Personal Information: Client’s name: __ gender: ___ religion/sect: __ Date of birth: __ age: _ marital status: ___, Education: __ Family information:
(it is a clinical case history in which you just need to fill this form. you just need to suppose a patient and accordingly you have to fill this form and must be in detailed)
Case History Sheet
Personal Information:
Client’s name: __ gender: ___ religion/sect: __ Date of birth: __ age: _ marital status: ___, Education: __
Family information:
Father’s name: ___ alive: ___ age: __
Mothers name: _____ alive: ____ age: _
- Presenting Problems ( Nature Of Problems, Precipitating Event, Patient’s Feelings And Thoughts About Problems)
__________________________________________________________
- History Of Problems (Duration Of Present Problem, Changes In Nature, And/ Or Frequency Of Problem Over Time, Prodromal Manifestations, Other Past Problems Of A Psychological Nature, No. Of Attacks)______________________________________________
- Prior Treatment (Details Of Problems Sought For Presenting Problems And For Whom ; When And For What Duration Treatment Undergone; Nature Of Treatment Methods ; Names And Dosages Of Drugs Taken; Ects , Faith Healing Etc; Response To Treatment Including Adverse Reactions And / Or Side Effects)________________________________________________
- Medical History ( Most Recent Physical : Date And Results; Current Medications ; Health Condition Since Childhood Including Details Of Serious Illness/Disabilities Suffered And Surgery Undergone ; Eating And Sleeping Habits If Remarkable And Any Change Of Same ; Use Of Stimulants, Alcohol And Drugs) _____________________________________________________
- Family History (Migrations, Births , Marriage, Serious Illness , Deaths , Jobs Of Earning Members , Relationship With Family Members)__________________________________________________
- School History( Marks/Divisions Obtained, School Changes, School Problems , Relationships With Peers And Teachers , Extra-Curricular Activities) _______________________________________
- History Of Friendships( Nature And Extent Of Friendships, Recreational Activities, Degree Of Religiosity, Sexual History-Premarital, Marital , And Extra Marital Sexual Relationships)______________________________________________
- Work/Occupational history:
Are you currently employed: ( ) no ( ) yes
Position and employer: _________________________
Are you satisfied with your current job and position: ______________________________
any work-related stressors, if any _____________________________________________
Orientation (Person, Place, Time) ________________
Sleep (Insomania, Nightmares, Sleep Walking)____________________________________
Attention ( Concentration, Memory)_____________________________
Perception (Illusions, Hallucinations-Auditory , Visual, Tactile, Somatic, Olfactory) _______________________________________________
Thought (Unusual Concept Including Suspiciousness And Delusions, Conceptual Disorganization Including Loosening Of Associations)_________________________
Affect (Crying Spells, Depression, Guilt, Feelings, Suicidal, Excitement, Hostility, Grandiosity, Blunted Affect) ____________________________________
Behavior ( Speech , Mute, Talkative, Abusive; Motor: Restless, Assaulting , Destructive, Excited , Motor Retardation)___________________________________
Mannerisms And Posturing ( Unusual Gestures, Preservative Moments)____________________ ____________
Anxiety( Tension, Nervousness, Phobias, Obsessions/Compulsions)______________ __________________
Somatoform ( Conversion, Hypochondriasis, Other Somatic Complaints)__________________ _________________
Psychosexual Problems: (gender identity, sexual dysfunctioning): _____________________________________
Psychosomatic (Obesity, Headaches, Painful Menstruations, Skin Disorders , Asthma, Ulcers, Nausea And Vomiting)____________________________
Addictions ( Prescribed Or Non-Prescribed Medications, Narcotics Use, Smoking , Pan/Tobacco Chewing, Alcohol Use, Gambling)____________________________
Family Psychopathology (Nature History And Treatment Of Mental Disorders In Members Of Patient’s Family)_______________________________
Personality Traits (Paranoid, Schizoid, Schizotypal, Antisocial, Borderline, Historic, Narcissistic, Avoidant, Dependent, Obsessive, Compulsive, Passive, Aggressive) _______________________________
Interview Behavior (Open, Secretive, Anxious, Relaxed, Withdrawn, Cooperative, Timid, Compliant, Opposition)
_______________________
Strengths (Degree Of Insight, Motivation, Intellectual Level, Mitigating Circumstances, Other Talents And
Tentative Diagnosis _________
What do you consider to be your strengths? __________________
What do you like most about yourself? _____________
What are effective coping strategies that you have learned? ___________________
What are your goals for therapy?________________
Recommendations (Also List Tests) _________________
Final Diagnosis ______________
Date Of Termination _____________________________________Unilateral/Bilateral
Reasons For Termination _______________________________
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