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Case History

This document contains a case history form that collects demographic and personal information about a patient. It requests details about the patient's name, age, address, education, family, medical history, personality, and reasons for their current condition. Specifically, it asks about any sleep or appetite issues, family medical history, the patient's development, education, relationships, social life, personality traits, and ultimate concerns. The form aims to gather a holistic understanding of the patient's background and current presenting issues.

Uploaded by

Aakanksha Verma
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57 views2 pages

Case History

This document contains a case history form that collects demographic and personal information about a patient. It requests details about the patient's name, age, address, education, family, medical history, personality, and reasons for their current condition. Specifically, it asks about any sleep or appetite issues, family medical history, the patient's development, education, relationships, social life, personality traits, and ultimate concerns. The form aims to gather a holistic understanding of the patient's background and current presenting issues.

Uploaded by

Aakanksha Verma
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Case History

1. Demographic Details

Name-

Age-

Address-

Education

Family Income

2. History of present condition-


Is there any sleep difficulties you are experiencing?
Is there any loss of apettite or an increase in apettite you are experiencing?
3. Family History

Parents-

Siblings-

Age of Siblings-

Gender-

Relationship with both the parents and siblings-

Education/Occupation-

4. Personal History

Mother’s pregnancy and birth(optional)- time of birth, maternal stress, presence of both the
parents, normal or caesarean)

Early development (who raised the patient, were adults of both the sexes were present, were
they emotionally close to the you, description of your family life and surroundings)

Childhood-

Schooling and education (good or bad experiences, marks achieved by them, friends in school,
interaction with the teachers)-

Relationship and attitudes towards sex-

Social circumstances-
Attitudes towards smoking-

Any past illnesses-

5. Assessment of personality

Relationship assessment (quality of friendships)

Use of leisure time-

Any pre-dominant mood and the emotional tone-

Character traits (what kind of person you are?)

Attitudes (Attitudes towards health and mental health)-

Ultimate concern (What and who matters the most to you and why?)-

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