SAMVAIDHNA'S CLINICAL CASE STUDY PERFORMA

SAMVAIDHNA
THE MENTAL HEA TH ORGANIZATION
S-1, PARK VIEW APARTMENTs, OLD VIJAY NAGAR, AGRA
DEVELOPED BY
Dr Vibha Sharma Dr.Amit Abraham
Senior Lecturer. Reader & Head
Department of Psychology Department of Psychology
St. John'g College, Agra St. John's College, Agra

1. GENERAL INFORMATION

Name : Father's Name:

Age: Sex: Education :
Occupation : Caste:s Religion :
Marital Status: Socio Economics Status :
Residential Address:

2. CHIEFCOMPLAINTS OR PRESENT PROBLEMS

a) In Chronological Order (Given by the patient himself and given by informant)
i)
ii
ii)
iv)
V)

b) Informant(s)
i) Relation
ii) How good & observed he is ?
iii) Reliability of the information
iv) Source of referral

3. DETAILED INFORMATION ABOUT PRESENT PROBLEMSA

a) Duration :

b) Precipitant Factor
i) Physical :
 AMAOSH GAVMA2
ii) Psychological

c)Onset
i) Acute
ii)Chronic
in) Insidious

d) Severity
i) Subjective discomfort
ii)Social functioning

e) History of any specific behavor pattern or alcohol/drug abuse (duration)

) Treatment History (What typeof treatments have been taken till now, with duration)

g) Specific enquiry about mood, sleep, appetite, social interactions, suicidal ri_k,
personal hygiene, job efficiency etc.

h) Concurrent physical illness (if any)

4. EXTENT QF IMPAIRMENT IN FUNCTIONING (should include activities of daily living

and extent of impairment in other areas of role of performances)
 (3)

5. PAST HISTORY
a) Medical or Physical History (including any major physical illness/ operations/
accidents)

b) Psychiatricmental
Historyillness):
(dates, symptoms, diagnosis, treatment and level of recovery of
any previous

6. FAMLY HISTORY
a) Family Tree

b) Information about parents (age, education, general personality, their mutual relationship.
relationship with parents etc.) (If deceased, age at death and cause)

c) Information about Siblings (same as above)

d) Childhood Home Situations

 (4)

e) Family history of illness

hPERSONAL HISTORYlNectiotsnt esb antetoseve zolb)voteik me

a) History of birth
i) Date and Place of birth
ii) Home or Hospital delivery
1) Prenatal, natal or postnatal complications (1f any)

b) Early Developments
i) Developmental milestones.:
ii) Neurotic traits (nail biting, bed wetting, phobias, tantrums etc.):

iii) Iness and injuries in childhood :

c) Educational history
i)Age at starting school:
i) Highest grade completed:
ii) Performance at school :
iv) Disciplinary problems, peer relationships and group participation
UAS TO1S1i (

v) Hobbies, special abilities

vi) Reasons for discontinuing:

d) Occupational history
i)Jobs held in chronological order
 (5)

ii) Adjustment with peers and

supervisors:
ii)Specific difficulties, promotions

iv) Reasons for change of jobs :

e) Sexual and marital history

i) Age at menarche, reaction to it,menstrual cycle, sex education (for females only)

ii) Masturbation and associated guilt feelings :

) Homosexual contacts, premarital and extramarital relationships :

iv) Marriage - love or arranged ? Date, age and education of spouse

v) General and sexual adjustment :

vi) Number of children, age, sex, occupation and their adjustment :

)Present living conditions (type of residence, members living there, sharing of income,
expenses, overall social support etc.):

g)Premorbid personality (personality before illness )- Personality traits, habits, hobbies,

passive/active, assertive, introvert/extrovert, sociability, anxiety, compulsive behavior,
general adjustment :
 (6)

h) History of alcohol and drug uptake intake (duration, amount,

/anyother drug effects):
History of alcohol consumption

8. PHYSICAL EXAMINATION

9. CLINICAL INTERVIEW FINDINGS

a) Consciousness :

b)General appearance and behavior - (sex, appearance, appropriate to age, personal

cleanliness, build, handedness, came to / brought to interview, awareness of surroundings,
eye to eye contact, reaction time, rapport, psychomotor activity, restlessness,
preoccupation, distractibility, tics, mannerisms, stereotype, other catatonic features,
behavior during interview):

c) Cognitive functions -(Atention and concentration (by counting backward, DF and DB),
inattention and neglect ) :

i) Language (Dysarthria, dysprosody, dysphasia, naming, hearing, writing, comprehension,

volume, spontaneity):

ii) Orientation
Time (day, date, week, month, year etc.):
Place (room, ward, hospital, city, state, etc.):

Person (identity of self,

time) : identity of others with respect to self, sense of passage of
 (7)

ii) Memory - Immediate (DF, DB)

Verbal (story immediate recall):
Recent (items of past meals. four unrelated words, four hidden objects, story for
delayed tecll ).

Recent (past, personal and impersonal events ):

iv) Abstraction (proverbs, similarities, differences ):

v) Judgment (test, personal, social) :

vi) General intelligence and information

(ask some general questions)

vii) Calculation and comprehension (ásk some simple calculations and proverbs etc.)

d) Thought -Form, stream, content, possession (include sample):

e) Mood
i) Subjective experience :
 (8)0yon
range, mobility, reactivity,
) Objective experience (equality, appropriateness,
communicability, liability etc.):

autoscopic phenomena -
f) Percept (Hallucination, pseudo-hallucination, imagery, illusion, patterns,
continuous / discontinuous, 3Dquality, control, clarity or veridicality, diurnal
types of
modality, content, response, objective or subjective, space, insight, special
hallucinations) :

g)Passivity phenomena notelsewhere described:

h) Other phenomena like depersonalization, phobias etc.

i) Insight (present or absent -whether patient is aware of his / her illness):

 (9)
PSYCHOLOGICAL REPORT
10, TESTS ADMINISTERED (Selection of tests should be made according to complaints,
history and mental status
i)
examination of thepatient)

ii)
ii)
iv)

l 1EST BEHAVIOR (patient's behavior during testing -

cooperative / uncooperative, came to
/brought to testing, in how many sessions testing could be
behavior during testing, - patient's version should be noted completed,
)
any speciic

12. TEST FINDINGS AND INTERPRETATlON-(Findingand interpretation of each test

should be given in order)
 prepated on the
RSUMMARY -Sunmary of the case canbe basIs of hustoy, M.SE and
test
indings
 (11)

14, CONCLUSION
DiagnosticImpression
Differential Diaynosis
Aplan of psychological manayementshould also be given