CASE RECORD FORMAT
SOCIODEMOGRAPHIC DETAILS:
Name :
Gender :
Age :
Address :
Marital Status:
Mother Tongue:
Education :
Occupation:
Religion :
Residence:
Family Type:
Number of Family Members:
Family Income:
REFERRALS
Source of Referral:
Reason for Referral:
INFORMANTS
Duration of relationship with client :
Duration and continuity of stay with the patient:
Consistency and Corroborativeness of information provided:
Reliability and Adequacy of Information Provided:
CHIEF COMPLAINTS:
As per Client: (Chronological order with duration)
As per the informant:
NATURE OF ILLNESS
Precipitating Factor:
Mode of Onset: Abrupt (within 48 hours)/Acute (48 hours to 2 weeks)/ Insidious (more
than 2 weeks)
Progress: Fluctuating/ Status Quo/ Improving/Deteriorating/ Episodic
HISTORY OF PRESENT ILLNESS:
(Details)
BIOLOGICAL FUNCTIONING (Increased/ Decreased/ Unchanged):
Sleep:
Appetite:
Sexual Interest and Activity :
Energy:
NEGATIVE HISTORY:
No history suggestive of presence of significant brain injury, epilepsy, intellectual disability,
false belief, false perception, significant mood episode, obsession, compulsion and any other
anxiety related conditions.
PRESENT MEDICAL ILLNESS:
TREATMENT HISTORY (For Present Illness):
Medical:
Psychiatric:
PAST ILLNESS:
Medical:
Psychiatric:
FAMILY HISTORY:
i. Family Tree: 3 generation genogram
ii. Consanguinity:
iii. Parental information
Father Mother
Age Age
Living/dead Living/dead
Education: Education :
Occupation : Occupation :
Relationship with/attitude towards
Relationship with/attitude towards
patient: patient –
iv. Family Interaction Pattern
a. Communication: Direct/ Indirect
b. Leadership:
c. Decision Making:
d. Role:
e. Family rituals:
f. Cohesiveness:
g. Family Burden:
h. Expressed Emotion– warmth/ supportive/ critical
comment/emotional over involvement
v. Family history of psychiatric illness:
PERSONAL HISTORY:
1) Birth & Developmental History
a. Type of Birth:
b. Birth Complications:
c. Milestones:
2) Childhood Disorders:
3) Parents & Home Situations in Childhood and Adolescence:
4) Home Environment: congenial/ non congenial
5) Academic History:
Age of school admission
Current academic grade
Academic record
Peer interaction
Any significant event: bully/abuse/complaints from school Reason
for discontinuation (if any):
6) Occupational History:
Age of first
occupation
Current occupation and position Work
record
Interaction with coworkers (seniors, juniors and contemporary):
Any significant event:
Reason for discontinuation (if any):
7) Menstrual History:
Menarche age
Menstrual symptoms
Age of menopause (if applicable)
8) Sexual History:
Age of sex education
Sexual activity
Significant relevant history
9) Marital History:
Age of getting married
Duration of Marriage
Spouse’s details
Relation with in laws and significant others
Reason for separation (if applicable)
Significant relevant history
10) Habits & Addiction: -
11) Pre-morbid Personality (For adult)/ general temperament (For Child)
MENTAL STATUS EXAMINATION (For adult)/ BEHAVIORAL OBSERVATION
(for child)
General Appearance & Behavior:
Touch with the surroundings
Eye contact
Attitude towards the examiner
Rapport
Speech:
Volume:
Reaction time to stimulus:
Speed:
Prosody:
Ease of speech:
Productivity:
Relevant to context
Coherent
Goal directed
Cognitive functions
o Orientation:
o Attention and Concentration:
o Memory:
Remote Memory:
Recent memory:
Immediate memory:
o Abstraction:
o General intelligence:
o Judgment:,
Personal:
Social:
Test:
Mood/Affect:
Subjective:
Objective:
Depth:
Range:
Stability:
Congruent to thought
Appropriate to the situation
Communicable.
Thought
Stream:
Form:
Possession:
Content:
Perception:
Other psychopathology:
Insight
DIAGNOSTIC FORMULATION
(Details)
PROVISIONAL DIAGNOSIS:
Points in favor Points against
DIFFERENTIAL DIAGNOSIS
Points in favor Points against
CONFIRMED DIAGNOSIS (IF APPLICABLE)
PSYCHOMETRIC ASSESSMENT DETAILS
PSYCHOPATHOLOGY FORMULATION (BIO PSYCHO SOCIAL MODEL)
MANAGEMENT PLAN
