ADULT CASE HISTORY FORM
File No.
Date:
Name Sex
Date of Birth Age Marital status: S,M,D, Sep
Present address
Permanent address
Phone Education Occupation
Father’s Name Age Edu Occ
Mother’s Name Age Edu Occ
Spouse Name Age Edu Occ
Siblings: M F B.O Children (Sex/Age )1 2 3
4 5 6 7 8 9
Family structure (nuclear/joint)
Head of family earning member
Income group Heritage
Languages
Appearance
Informant’s name Relationship
Information address/phone
Referenced By
Presenting Problems (verbatim)
1
Assigned to: (for assessment)
(for therapy)
Fee Payer
Intake by:
Other information: -
Tentative Diagnosis
Date of Termination unilateral/bilateral
2
Case History Sheet
Chief complains (nature of problem, precipitating events, patient’s feelings and thoughts about problems).
History of complaints (duration of present problem, changes in nature, intensity, and/or frequency of
problem over time, prodromal manifestations, other past problems of a psychological nature no of attacks).
Prior psychiatric history (details of treatment sought for presenting problems and form whom; when and for
what duration treatment undergone, nature of treatment methods; name and dosages of drug, taken; ECTs
faith healing etc; response to treatments including adverse reactions and/or side effects).
3
Medical history (most recent physical exam data and results current medications health condition since
childhood including details of serious illnesses/disabilities suffered and surgery under go; eating and
sleeping habits if remarkable and any change of some use of stimulants, alcohol and drugs).
Family History (migrations, births, childhood history, developmental milestones, marriages, serious
illnesses, deaths, jobs on earning members, relationship with family members).
School history (Academy academic, school changes school problems relationships with peers and
teachers, extra curriculum activities.
History of friendships (nature and extent of relationships, recreational activities)
Sexual history (premarital, martial and extramarital sexual relationships).
4
Job history (nature of jobs held and remuneration reasons for job changes relationships with juniors
colleagues, and bosses.)
Personal history (merits and demerits, hobbies, sports, daily routine and ambitions.)
Degree of religiosity
5
Mental State
Orientation (person, place time)
Sleep (insomnia, nightmares, sleepwalking)
Attention (concentration, memory)
Obsessions, Compulsions
Perception (illusion, hallucinations, auditory, visual, tactile, somatic, olfactory)
6
Though content (unusual contents including suspiciousness and delusions conceptual disorganization
including lessening of associations)
Affects (crying spells, depression guilt feelings suicidal, excitement, hostility, grandiosity, blunted affected)
Behavior (speech: mute, talkative, abusive, motor rest lessens, assaultive destructive, excited, motor
retardation)
Mannerism and posturing (unusual gestures; preservative movement)
Anxiety (tension, nervousness, phobias, obsessions/compulsion)
Somatoform (conversion, illness related anxiety, other somatic complaints)
7
Psychosexual (gender identify, paraphilia’s, psychosexual dysfunctions)
Psychosomatic (obesity, headaches, painful menstruation, skin disorders, asthma, ulcers, nausea and
vomiting)
Addictions (prescribed and non-prescribed medication, narcotics use smoking pan/tobacco chewing alcohol
use gambling)
Family psychopathology (nature, history and treatment of mental disorder in members of patient’s family)
8
Personality traits (paranoid, schizoid, schizotypal, antisocial borderline, histrionic, narcissistic, avoidant,
dependent, obsessive compulsive, passive aggressive)
Interview behavior (open, secretive, anxious, relaxed withdrawn, cooperative, timid, aggressive compliant)
Strengths (degrees of insight, motivation, intellectual level, mitigating circumstances, other talents and
resources)
Tentative diagnosis
Differential Diagnosis
Recommendations (also list tests)
9
Case conference diagnosis Date
Date of termination Unilateral/Bilateral
10
