----- ----- ----- ----- ----- ----- ----.
CASE HISTORY PERFORMA
(A) SOCIO DEMOGRAPH IC DATA
I NAME 2 FATHER'S NAME
3 AGE 4 SEX
5 EDUCATION 6 OCCUPATION
7 socro ECONOMIC STATUS 8 MARITAL STATUS
9 RELIGION 10 REFERRAL
1I ADDRESS 12 MOBILE NUMBER
13 INFORMANT 14 DA TE OF ADMISSION
15 REGISTRATION NO. 16 RELIABLITY AND ADEQUACY
(B) CHIEF COMPLAINTS {IN CHRONOLOG ICAL ORDER WITH DURATION)
(C) HISTORY OF PRESENT ILLNESS
I. ONSET
I. I.Abrupt 1.2. Acute 1.3. Insidious
2. DURATION
2.1. Continuous 2.2. Episodic 2.3. Fluctuating
3. PROGRESS
3.1. Improving 3.2. Deteriorating 3.3. Static
4. FACTORS OF ILLNESS
4.1. Predisposing Factor
4.2. Precipitating Factor
4.3. Perpetuating Factor
4.4. Limiting Factor
HISTORY OF PRESENT ILLNESS (Contd.)
(D) NEGATIVE HISTORY
(E) TREATMENT HISTORY
PAST PSYCHIATRIC/MEDICAL HISTORY
(F) FAMILY HISTORY
Family Type: Nuclear/Joint Family
Family Atmosphere/ Relationship amongst Family member:
Family Attitude towards Patient's illness:
Family History of major illness like any hereditary illness, mental illness, M.R., epilepsy, substance abuse,
suicide etc.
(G) PERSONAL HISTOR\
I. Birth and Early Developmenc: (was birth full term. ddivc:rcd at hospital/home. any complications. and illness
in post natal period, birth cry and developmental milestones)
2. Beha,dour during Childhood: (sleep disturbances, temper tantrum. bedwetting, any childhood disorder)
3. Physical illness during Childhood:
4. Home atmosphere in childhood and adolescence (disturbed/congenital/abnormality of family situatio11 and
also patient's attitude towards parent)
5. Scholastic and Extracurricular Activity: Uoining, type of school, performance, attitude towards peers and
teachers)
6. Vocational/Occupational History: (age of starting work,jobs held, reasons for leaving. ambitions, competence)
7. Menstrual History:
8. Sexual History:
9. Marital History:
IO. Forensic History:
11. General pattern of living:
(H) PREl\tORBIO PERSONALITY
l. Social Relation: (relation to family uttnchment/dercndcnt, to friends, grours, workmates,
lender/followcr/nggn:ssive or submissive, nmbitious, adjustnblc, indcrendcnt)
2. Intellectual acti\'ities. hobbies, and use of leisure time:
3. Predominant Mood:(cheerful/worrying/placid, optimistic/pessimistic, mood stable/unstable, expresses
feelings or loses control over feeling)
4. Character:
4. l. Attitude to Self: (egocentric, selfish, dramatizing, self-conscious, strengths, abilities, hopes, ambition,
aspiration)
4.2. Attitude tn \Vnrk and Respnnsihility:
4.3. Interpersonal Relationships: (Self-confident or shy/timid, Ability to trust others, make and sustain
relationships, Responsibility, capacity to make decisions, adaptive or not, Guardedness,
dominant/submissive, friendly/emotional)
4.4. Standards in moral, religious and health matters:
4.5. Energy and Initiative:
5. Fantasy Life:
6. Habits:
7. Reaction Pattern to Stress:
(1) MENTAL STATUS EXAMINATIO N
1. GENERAL APPEARANCE AND BEHAVIOUR: (Physical Appearance. Estimate of Age, Body built, Touch
with Surrounding. Eye contact, Dress, Facial Expression)
2. ATIITUDE TOWARDS EXAMINER:
3. PSYCHOMOT OR ACTIVITY:(Inc reased/Decrease d/Normal)
4. SPEECH: (Patient speaks spontaneously or only in response of questions, amount of speech little or excessive,
Pitch, Quality, Prosody, Tone high/low, Tempo fast/slow, Reaction time, Speed, Ease of Speech, Relevance,
Coherence, Goal Direction)
5. MOOD AND AFFECT: (quality, intensity, range, mobility, reactivity, congruity, diurnal variations &
appropriateness)
Subjective:
Objective:
6. THOUGHT:
1. STREAM: volubility, Flight of ideas, Prolixity, Retardation, Poverty of speech, Circumstantiality,
Tangentiality, Perseveration, Thought blocking.
11. FORM: FTD, loosening of association, Derailment
111. POSSESSION: Obsession, Rumination, Compulsion, Thought alienation, insertion, withdrawal,
broadcasting, echo.
1v. CONTENT: Worry, Phobia, Impulse, Somatic complaint, Daydreaming, Antisocial urge, Suicidal ideas,
death wish, Delusion, Overvalued idea,
7. PERCEPTUAL DISORDER: (illusions an<l hallucinations)
8. HIGHER COGNITIVE FUNCTIONS:
8.1. LEVEL OF CONSCIOUSNESS: (Normal/Clouded/Abscrdation/Drowsiness/Stupor/Coma)
8.2.ORIENTATION: (Date, Person, Place and Time)
8.3.ATTENTION AND CONCENTRATION: (Attention arousal: Digit forward, sustainability: Digit backward
s
& concentration; days or months backwards or Subtracting of serial 3 from 40)
DF: 573,5387, 16495,341796, 7259433,47291685
DB:417.6158, 29763,615839,4715386,92583174
20-1:
40-3:
8.4. MEMORY: (Immediate: digit repetition, Recent: enquire about breakfast, events of the day. Remote: ask
various personal and impersonal events)
I Immediate Memory:
II Recent Memory:
Ill Remote Memory:
8.5. VISUAL-SPATIAL ABILITIES:
9. ABSTRACT ABILITY: (Similarities, Differences and 1.:ommon proverbs)
DIFF. - I. Stone - Potato
2. Fly- Butterfly
3. Cinema - Radio
SIM. - I. Orange - Banana
2. Dog-Lion
3. Eye - Ear
PROVEBS:
9.1.ARITHMETIC & CALCULATIONS:
9.2. GENERAL FUND OF KNOWLEDGE: (Name of PM, Name of state, Capital, CM, Major cities or rivers, name
of countries)
JO. JUDGMENT:
I. PERSONAL: A. PRESENT
B.FUTURE
II. SOCIAL: GUEST
II. TEST: A. ENVELOPE
B. FIRE
11. INSIGHT: GRADE:
(.n DIAGNOSTIC SUMMARY
(K) CASE FORMULATION
(L) DIAGNOSIS
(M)ASSESSMENT PLAN
