Angel Clinic mind & body holistic centre
CASE HISTORY FORMAT
1. IDENTIFICATION DATA
Name:
Age:
Gender:
Educational Qualifications:
Occupation:
Marital Status:
Socio-economic status:
Living condition:
Languages known:
Religion:
Nationality:
Place of Residence:
Date of assessment:
Primary reasons for seeking help: health/psychiatric/job/ family/legal.
2. INFORMANTS: (Details of informants, including their relationship to patient)
3. PRESENTING COMPLAINTS (from patient and informant)
4. CHIEF COMPLAINTS (In chronological order with Duration)
Age of first onset of use the substance
Course:
Episode:
Progress:
Treatment:
5. DRUG USE HISTORY/ HISTORY OF PRESENT ILLNESS:
(a) Age of initiation of substance, reasons for initiation and continuing use, acute effects
(b) Age at which regular daily use started, progression of use over time
(c) Change effects experienced over time (tolerance)
(d) Ask when withdrawals first experienced, nature and severity of withdrawals,
complicated withdrawals (delirium, seizures etc , if any)
(e) Craving to take substance
(f) Pattern and frequency of use: (Ask about the usual dose current (past 1 month)
consumption, maximum dose and last dose)
6. HIGH RISK BEHAVIOUR
(For IDUs): Needle use practices:
Sharing of needles
Sharing of syringes, cotton, vials, or other paraphernalia
Cleaning practices
Sites of injection use iv/im; any dangerous sites of use
Reuse of needles and syringes
Places where injections are taken
Needle site complications
(For all substance users): Unsafe sexual practices:
Multiple partners, sex with CSW; Anal sex; barrier methods
Knowledge of HIV/AIDS
7. PERIODS OF ABSTINENCE AND TREATMENT, IF ANY
(a) Number/duration of abstinent attempts, reasons for seeking abstinence
(b) Nature/type of treatment sought, duration of treatment
(c) Level of functioning during abstinence
(d) Use/escalation of any other substance during abstinence
(e) Reasons/circumstances of relapse
8. PAST HISTORY: Physical and psychiatric illness history
9. FAMILY HISTORY:
Family history of drug use, psychiatric illness
Family’s Attitude towards Illness
Current living arrangements
Social support
Reason for seeking treatment currently
10. PERSONAL HISTORY:
Developmental History (this heading will include prenatal, natal and post-natal
history i.e birth complications, nature of delivery, developmental milestones etc)
Childhood history :(presence of early childhood disorders)
Home environment: (living Conditions and who all in family, rooms, income,
earning members etc)
Educational History (will also include play behavior)
Vocational History
Occupational History
Marital History and Sexual
11.TEMPERAMENT/PREMORBIDTEMPERAMENT/PREMORBID
PERSONALITY (CHOOSE THE HEADING APPLICABLE TO YOUR CASE)
Premorbid Personality:
Social relations:
Intellectual activities: (hobbies and interest etc)
Mood: (bright, cheerful and relaxed etc.)
Character:
I. Attitude to work and responsibilities
II. Interpersonal relationships:
III. Standards in moral, religious, social and health matters:
IV. Energy, initiative:
V. Fantasy life:
VI. Habits:
Impression:
12. Intake: Examination.
(Detailed physical examination: illnesses & complications. assessment of withdrawal.
Physical examination can point to evidence of drug use e.g. injection marks or inhalant
stains. The evidence of physical harm as a result of drug use should be looked for).
13. Behavioural Observation/Mental Status Examination
General appearance and behaviour
Attitude and relationship towards examiner
Motor Behaviour (Posture, Reactive movements, Grooming movements, Expressive
movements, pathological movements and goal directed)
Insanity of the movements
Speech (Rate,Tone,Volume,Reaction)
Consciousness and Orientation: (Time, Place, Person)
Higher Cognitive Functions:
Attention and Concentration:
Memory
Immediate Memory
Recent Memory
Remote Memory
Abstract thinking:
General fund of Knowledge:
Athematic Calculations:
Intelligence:
Affect:
Subjective-
Objective-
Impression-
Thought – Stream:
Form:
Possession:
Content:
Perceptual Disorders: (Hallucinations and Illusions)
Judgment – Test, Social, Personal
Insight:
Motivation: Assessment of patient’s motivation is very important. A patient can be
considered to have a good motivation if there is
• Acceptance of the problems associated with drug use
• A strong desire to quit
• A high ‘internal locus of control’ (takes responsibility for own behaviour and actions
rather than blaming external factors)
14.Diagnostic Formulation:
Diagnosis should include the following:
Primary drug status
Secondary drug status
Physical co-morbidity
Psychological morbidity
Psychosocial issues
(Based on the information obtained during the interview, it will be possible to summarize
the patient’s problem and understand whether he has a pattern of harmful use or
dependence syndrome (addiction) as per ICD-10 (International Classification of Diseases,
10th edition).
Provisional Diagnosis:
Points in favour:
Points in against:
Differential diagnosis:
Assessments Administered
S. No. Name of Test Rationale
Test Behavior:
Test Findings:
Summary:
Impression:
Prognostic Factors
Poor:
Good:
Management Plan
Short term Goals
Long Term Goals
Examiner Supervisor
Signature Signature
Date Date
