CASE RECORD
DEMOGRAPHIC DATA
Name
Date of birth
Age
Sex
Father's name
Occupation
Mothers name
Total fa:nily income
Present ad iress
Locality
:0C/BCIMBC/DNCISC/ST
Community &Caste
Religion
Mother tongue
Language spoken at home
1.Q & Level of intellectual functioning:
Present complaints
Behaviour Problems
1
FAMILY HISTORY
S.No Name Relationship Education Age Occupation If they have any
disability
(Specify)
Type of Family:
Are the parents related
Treatment of the child in the family :
Is there any family history of epilepsy,
MR/V.J/H.L/or other disabilities.
If yes specify
PEDIGREE CHART
Medical History
Age of onset of the problem
Causes
Age of identification
2
Treatment of any kind
Any additional disability
PRENATAL HISTORY
Attempted abortion
Threatened ahotion
Rh - incompatability
Bleeding during 1" trimestcr;
Bleeding during later pregnahcy:
Trauma
Hypertension
Diabetic
Jaundice
Foetal movement
Infection
Radiation
Drugs
Other disability
PERINATAL HISTORY
Delivery places
Term
Labour duration
Delivery type
Birth weiglt
Birh cry
3
Colour of the baby
Congenital anomalies
infections
Feeding problems
Convulsions
Others (specify )
POSTNATAL
Infection:
Jaundice
Convuisions
Injury
Nutritional disorders
Others (specify )
IMMUNISATION HISTORY
Polio
Diphtheria
Pertusis
Tetanus
Measles
DEVELOPMENTAL HISTORY
A. Motor Milestones
Head control
Sitting
4
Standing
Waiking
B. Speech and Language
Babling
Two word phrases
Sentences
C. Adaptive
Avoiding common dangers
D. PersoLal / Social
Smiles at others
Responds to name
Feeds self
Dresses self
Toilet control
EDUCA TIONAL HISTORY
Name of the schoo!
Type of the school
Class
Duration of schooling
Attendance
5
OCCUPATIONAL HITORY / TRAINING EXPERIENCE
Previous work / iraining experience
The Kind of work / training experience
Place of work / training
OBSERVATIONS
Learning
Enthusiasm in the class
Contributing in the class
Relationehip with peers
Test performance
Attention and memory
Relationship with the teacher
Performance in the assigned work
b. Work Environment
Relationship with staff
Relationship with peers
Liking to words the work
Working capacity
Future plans
Performance
Curricular) Specify
c. InstitutionalActivities (Extra
Iaitiation
Involvenment
Participation in extracurricular activities
d. Hostel Environment
Interpersonal relationship
Helping tendency
Problem solving
Cooperation
Friendship with others
Emotional wellbeing (Mental health):
e. Home environment
Tamily invol vement
Personal need of the case
Educational Activities
Play and leisure activities
Interpersonal relationship with
Father
Mother
Siblings
. Social Environment
Neighbour ---hood interaction
Participatio 1in socio-religious activities:
perceived by family:
Reason for the condition of the case as
GENERAL
Heaith and hygiene
Discipline and order lines e
Discipline and order lines
PLAY
Play behavior
(a) Enjoys play
(b) Not interested
(c) Observe others playing
Reasons for poor play behaviour
1. No companions
.2. Peer group avoid playing
3.Quarrelsome
4. Overprotection
S. Poor play facilities
6. Others (specify)
Leisure time Activities
SEXUAL HISTORY
Aitained menarche
Secondary sexual characteristics
8
PHYSICAL EXAMINATION
Head
Eyes
Ears
Nose
Hair
S:in
Vision
Audition
Speech
Limbs
Loft hand
Left leg
Right lcg
Right hand
COGNITIVE SKILLS
: Good/ Fair/inattention
Attention
Yes/ NO
Follows simple instrvctions
hazards yes / No
Awareness of danger &
Cause
Concept Formi tion [,X)
Number:
Size : Shape
Colour:
Academic skills (Good, Average, Poor)
Reading
Writing
Arithmetic
Addition
Subtraction
Multiplication
ivisicn
BEHAVIOURAL HIS1 uRY
Mood
iNormal
Elated
Depressed
Frustrated
Irritable
Destructive behavior
Odd behavior
Withdrawn behaviuor
Hyperactive behaviour
THERAPIES & RECOMMENDATIONS
Recorded By
Date:
10
