CASE FORMAT

CASE HISTORY

Socio-Demographic Details

1. Name:
2. Age &DOB:
3. Sex: (Female/Male/Other)
4. Religion:
5. Socio-economic status: (Upper/Middle/Lower)
6. Family Income:
7. Family type: (Joint/Extended/Nuclear/Living alone)
8. Location of residence: (Rural, Urban or Suburban)

Case Report

 Informant: (If it is not the client, specify name, age, relationship with the client)
 Reliability of Information: (Reliable/Partially reliable/Unreliable)
 Adequacy of Information: (Adequate/Inadequate)

Presenting Complaints

(Write current condition of the client involved)

History of problem (Narrative history- background of the family and its

dynamics,psycho-social issues, medical condition)

Impact of the problem(Narrative-social, physical, emotional and psychological)

PAST PSYCHIATRIC HISTORY

(History of any mental illness and their treatment details)

PAST MEDICAL HISTORY

(History of any physical illness and their treatment details)

FAMILY HISTORY

Genogram

 Consanguinity of parents: present/absent

 Family history of mental illness: present/absent

 Background of the family:

  Cultural Beliefs and Values: Traditional/Liberal
Social Support System:
Primary: weak/strong
Secondary: weak/strong
Tertiary: weak/strong
 No of earning members and their monthly income:
 Communication pattern in the family: Cordial/ Strained
 Interactions of the client to other family members: Cordial/ Strained
 Special attachments of client in the family:
 Any separation from family members: Present/ Absent
 Relationship with parents:

Father: Attached, Detached, Possessive, Dependency, Oppositional

Mother: Attached, Detached, Possessive, Dependency, Oppositional
Relationship with siblings: Cordial, Well Adjusted, Rivalry, Fighting/
Quarrelling

PERSONAL HISTORY

1. Perinatal History: any complications, gestational period, type of birth, any illness
etc)
2. Developmental milestones(specific)

3. Childhood History:
(Whom with the client grown up, separation anxiety, any accidents, play history, conduct
etc)
4. Educational History
 Age at which schooling began:
 Education level/class
 Major mile stones of education: beginning and ending year outcome(total
percentage)
 Intelligence/Scholastic performance: Below Average/ Average/ Above Average
 Favourite Subject:
 Difficult Subject:
 Truancy/Disciplinary problems: Present/ Absent
 Relationship with teachers: Respectful/strained/ Oppositional
 Relationship with peers: Cordial,/strained (Any other significant History)
 4. Educational History
 Age at which schooling began:
 Education level/class
 Major mile stones of education: beginning and ending year
outcome(total percentage)
 Intelligence/Scholastic performance: Below Average/ Average/ Above Average
 Favourite Subject:
 Difficult Subject:
 Truancy/Disciplinary problems: Present/ Absent
 Relationship with teachers: Respectful/strained/ Oppositional
 Relationship with peers: Cordial,/strained
(Any other significant History)

5. Psycho-Sexual History: Female

 Menstrual history

Age of menarche:

Menstrual cycle: regular/ irregular

Associated problems: pain/excessive bleeding/ emotional disturbances

6. Psycho-Sexual History: General

 Knowledge about Sex(Age appropriate):
Adequate/Inadequate/Healthy/Unhealthy
 Mode of gaining sexual knowledge: Friends/Books/Internet/Relatives
 Masturbatory practices: No knowledge/ Practice with Guilt/Healthy
 Any Sexual abuse in childhood/ Adolescence/: Present/Absent/by
any familymember/relative/ others

7. Premorbid Personality

(Nature of Personality of client before the onset of the problem)

 Nature: Introvert/ extrovert/ dominant/ submissive

 Predominant Mood: Anxious/ Cheerful/ Optimistic/Dysthymic/Irritable/Labile
 Emotionality: Balanced/ sensitive/ short tempered
 Relationship with people:
o Family: loving and caring/ cold and aloof/ responsible/ trusting/Suspicious/
Selfish/ helping/good to others but not to family
o Friends: having many friends/ cold and aloof/ cooperative/
trusting/Suspicious/ Selfish/ helpful to others/ living for friendship
o others: friendly/ cold and aloof/ cooperative/ trusting/Suspicious/
Selfish/helpful to others/
  Hobbies: Nothing specified/passionate
 Attitude towards religion and faith: believer /atheist/ moral/overly religious
 Attitude towards Self: self-critical/ good self-concept/poor self-concept/
 Attitude towards work and responsibilities: responsible / lazy

MENTAL STATUS EXAMINATION

General Appearance and Behaviour

 Personal hygiene: well kempt and tidy/ functional/dishevelled

 Grooming: well groomed/functional/poorly groomed/excessive
 Eye to eye contact: established and maintained/ established but not maintained/ not
established
 Rapport: over familiar/easily established/established with difficulty/guarded and
uncooperative
 Psychomotor activity: Increased /normal/ decreased.
 Any tics or mannerisms: Present/ Absent
 Any catatonic phenomena: Present/ Absent

Speech

 Coherence: Coherent/incoherent
 Relevance: Relevant/ irrelevant
 Reaction time: Quick/normal/Delayed
 Quantity: Talkative/ spontaneous/ expansive/ paucity/poverty.
 Rate: pressured/fast/normal/soft
 Volume: Loud, normal, soft
 Tone: Normal/monotone
 Fluency: Slurred, fluent and clear, stuttering.

Thought Process
 Stream: Flight of ideas/poverty/perseverance/circumstantiality / thought block/
tangentiality
 Form: Loosening of association, derailment/ neologism/clang associations
 Possession: obsessions/compulsion/ thought insertion/ thought withdrawal/ thought
broadcast
 Delusions: Persecution/jealous/love/guilt/grandiose/nihilistic/ill health/poverty
 Depressive cognitions: Hopeless/helpless/worthless/ suicidal/ homicidal ideas/ phobias/
anxieties
Perception
Hallucinations: Thought echo/ auditory/visual/olfactory/gustatory/tactile
Others (illusions, sensory distortions etc)
Mood: (Subjective)
Affect: (Objective)
Quality: Sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated,
euphoric, anxious, animated, irritable.
 Appropriate to situation/ inappropriate to situation
Cognitive functions (Age appropriate)
 Orientation:
Time: intact/ impaired
Place: intact/ impaired
Person: intact/ impaired
(Questions and answers should be noted)
 Attention and concentration
Not aroused/ Aroused but couldn’t sustain/ Aroused and Sustained
 Memory
Immediate: intact/ impaired
Recent: intact/ impaired
Remote: intact/ impaired
(Questions and answers should be noted)
 Intelligence:
General information: adequate/ inadequate
Comprehension: adequate/ inadequate
Arithmetic: adequate/ inadequate
Global impression: below average/ average/ above average
(Questions and answers should be noted)
 Thinking
Absractability
Similarities: Concrete/Abstract (banana and apple...)
Differences: Concrete/ Abstract( fly and butterfly...)
Proverbs: Concrete/Abstract ( pazhanchollu...)
 Judgement
Personal: intact/impaired( about the client)
Social: intact/impaired(social situations)
Test: intact/impaired(fire test, letter test...)
Insight (patient’s level of awareness about problem)

(Out of 6)

[Grade I: Complete Denial

Grade II: Slight Awareness But Denies Overall
Grade III: Aware, Blames Unknown Factors
Grade IV: Aware, Blames Physical Reasons
Grade V: Intellectual Insight
Grade VI: True Emotional Insight]

PROVISIONAL DIAGNOSIS
(Using ICD)

CASE SUMMARY
(Significant points from History, MSE Examination & include any Relevant past history,
family history, predisposing, precipitating, perpetuating factors etc)

INTERVENTION/PROFILE OF ACTIVITIES

PRINCIPLE/TOOLS/TECHNIQUES OF SOCIAL CASE WORK APPLIED (IN

POINTS WITH JUSTIFICATION)

CASE FORMULATION (Bio-psycho-social model)