Case Work- Up Performa Date
Department of Clinical Psychology; Faculty of Behavioral Sciences
A) PERSONAL INFORMATION- C.R. No.-
a) Name: h) Income:
b) Father’s name: i) Religion:
c) Age: j) Marital Status:
d) Gender: k) Socio economic status:
e) Educational qualification: l) Address:
f) Occupation: m) Referred by:
Reason of Referral:
B) INFORMANT-
(Informant’s name, age, education, relationship, time living & spent with the client)
Reliability and Adequacy of the Information:
CHIEF COMPLAINTS: DURATION:
By patient
By Informant
Onset: a) acute b) Sub acute c) insidious
Course: a) Continuous b) Episodic
Progress: a) Deteriorating b) Static c) Improving
Total Duration of illness:
Predisposing Factors:
Precipitating Factors:
Perpetuating Factors:
C) HISTORY OF PRESENT ILLNESS-
D) NEGATIVE HISTORY
E) TREATMENT HISTORY
Past history of medical illness/ treatment:
Past history of Psychiatric illness/treatment:
F) FAMILY HISTORY:
G) FAMILY GENOGRAM:
H) PERSONAL HISTORY-
1. Birth History:
2. Early Developmental History:
3. Childhood History:
4. Scholastic and extracurricular activities (Age, type of school, performance, regularity, peer relationships,
interest present status and reason to stopped education (if so)
5. College history (Particular adolescent emotional or physical problem)
6. Occupational history:
7. Menstrual history:
8. Sexual and Marital history (marital history, sexual issues, attitude towards pregnancy, sexual practices
including paraphilia/ sadism etc.)
9. Religious History:
10. Legal History:
I) PREMORBID PERSONALITY-
a) Social relations:
b) Intellectual activities, hobbies and use of leisure time:
c) Predominant mood:
d) Character (attitude to self, work and responsibility, interpersonal relationships, standards in
moral, religious and health matters, energy):
e) Habits & Dependence:
MENTAL STATUS EXAMINATION
A. APPEARANCE-
1. General appearance (physical appearance, estimate of age, body built, touch with surroundings, eye contact,
posture
2. Attitude & Behavior towards examiner & rapport:
3. Psychomotor activity:
B. SPEECH
Spontaneous/ non spontaneous
Quality (timbre and prosody)
Reaction time
Productivity/rate
Coherence, goal directed
(Intensity, relevance, coherence, ease of speech, reaction time, goal direction, productivity):
a) Pitch: High/ Low/ Normal
b) Tone: Raised/ Normal/ Low
c) Volume:
C. MOOD AND EFFECT-
1. Mood:
Subjective
Objective
2. Affect (Quality, intensity, mobility, range, reactivity, communicability, appropriateness, Congruence):
D.THINKING
1. Flow/Stream (volubility, acceleration, pressure speech, flight of ideas, prolixity, retardation, poverty of
speech, circumstantiality, tangentially, perseveration, thought blocking)
2. Form (loosening of association, neologism, derailment, over inclusion):
3. Possession (obsessions, compulsions, rumination, thought alienation, thought insertion, thought withdrawal,
thought broadcasting, thought echo)
3. Content (worry, somatic symptoms, religious preoccupation, depressive cognition, suicidal ideas, death
wishes, inflated self esteem, ideas, over-valued ideas, and delusion):
4. Perceptual Disturbances
a) Sensory distortion (change in intensity, quality, spatial form)
b) Sensory deception (hallucination, illusion, imagery)
5. Other psychotic phenomena (somatic passivity, made phenomena)
6. Other phenomena (depersonalization, derealization, body-image disturbance, paramnesia)
E. HIGHER MENTAL FUNCTIONS
1. Conscious, oriented-
2. Attention and Concentration-
Digit forward- Serial Subtraction-
Digit Backward-
3. Memory
a) Immediate Memory: c) Remote Memory:
b) Recent Memory:
4. Intelligence
a) General fund of Information:
b) Simple and Complex:
5. Abstract Thinking
a) Similarity:
b) Difference:
c) Proverb:
6. Judgment
a) Personal judgment:
b) Social judgment:
c) Test judgment:
7. Insight
i. Complete denial of illness.
ii. Slight awareness of being sick but denying at the same time.
iii. Awareness of being sick but blaming it on external factors.
iv. Awareness that illness is due to something unknown in the patient.
v. Intellectual insight.
vi. True emotional insight.
DIAGNOSTIC FORMULATION-
DIAGNOSIS:
PLAN OF ACTION-(ASSESSMENT & MANAGMENT)
SIGNATURE
