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Case Record Proforma-NDA

This document contains a case record proforma used by trainees in the Department of Clinical Psychology at NIMHANS Digital Academy. The proforma collects identifying information about the client, details about their chief complaints, history of present illness, past psychiatric/medical history, family history, personal history, mental status examination findings, diagnostic impression, and proposed management plan. It aims to provide a standardized format for documenting all relevant clinical information about a client in a comprehensive yet concise manner.

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Swati Tiwari Life Coach
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489 views4 pages

Case Record Proforma-NDA

This document contains a case record proforma used by trainees in the Department of Clinical Psychology at NIMHANS Digital Academy. The proforma collects identifying information about the client, details about their chief complaints, history of present illness, past psychiatric/medical history, family history, personal history, mental status examination findings, diagnostic impression, and proposed management plan. It aims to provide a standardized format for documenting all relevant clinical information about a client in a comprehensive yet concise manner.

Uploaded by

Swati Tiwari Life Coach
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NIMHANS DIGITAL ACADEMY

Dept. of Clinical Psychology


Case record Proforma

Date: Trainee’s Name:

Client’s Identifying Data:


Name - only initials. E.g.- Mr. A (Do not mention full name because of confidentiality
issues)
Age –
Sex –
Education –
Occupation –
Marital Status –
Socioeconomic Status –
Residence – Urban/rural

Informant:

Present Absent

If informant is present, then specify relationship with client:

Reliability of Reliable Not Reliable


information:
Adequacy of Adequate Not Adequate
information:

Chief Complaints/Client’s reason for seeking treatment:

Onset of symptoms/problems: acute/insidious

Course of symptoms/problems: continuous/episodic

Duration of symptoms/problems:

Precipitating Factors/Stressors:

Present Absent

If Present, specify:

History Of Mental Health Problems:


Associated Disturbances (E.g., sleep, appetite, socio-occupational functioning):

Negative History (absence of organic causes):

Past History:

Past psychiatric history –

Past medical and surgical history –

Family History:

Genogram –
Family history of major physical illness –
Family history of psychiatric illness –
Current living arrangement –
Interpersonal relationship –
Family’s knowledge of client’s illness/problems –
Family’s attitude towards client’s illness/problems –

Personal History:

Birth History –

Behaviour during childhood –

School History –

Occupational History –

Menstrual History –

Sexual History –

Marital and Relationship History –

Substance Use History: Present/Absent

If Present, specify:

Premorbid Personality (i.e., before onset of mental health problems):


● Social relations –
● Intellectual activities –
● Mood –
● Character
o Attitude to work –
o Interpersonal relationships –
● Energy and Initiative –
● Habits –
Mental Status Examination:

General Appearance and Behaviour:


● Alertness
● Appearance
● Nutritional status
● Dress and grooming
● Eye contact
● Posture
● Motor activity
● Any involuntary or abnormal movements
● Attitude towards examiner
● Rapport

Speech:
● Tone
● Tempo
● Volume
● Prosody
● Coherence
● Relevance

Emotion:
 Mood
 Affect (quality, range, reactivity, intensity, mobility, appropriateness)
o As reported by the client:
o As observed by Psychologist:

Thought:
● Form
● Stream
● Possession (obsessions and compulsions)
● Content (phobia/homicidal or suicidal ideas/delusions)

Perception (hallucinations/illusion):

Cognitive functions:
● Consciousness
● Orientation (time, place, person)
● Attention and concentration
● Memory (immediate, recent, remote)
● Intelligence (general information, comprehension, arithmetic/calculation, abstraction)
● Judgment (personal, social, test)
Insight about Illness (Present/absent/partial insight):

Diagnostic impression: (Depression/Anxiety Disorder/Psychosis/Substance use


disorders/Nil diagnosis)

Biopsychosocial model to understand the client’s illness/problems (Risk, precipitating,


maintaining and protective factors):

Management Plan:
● Referrals –
● Psychosocial intervention –

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