CASE HISTORY (CLINICAL INTERVIEW)

1. Identification Data
Name (Full identity) :
Age :
Sex :
Educational Qualifications :
Occupation :
Religion :
Marital Status :
Economic Status :
Vegetarian / Non-Vegetarian :

2. Chief Complaints -
Duration

3. Family History
Family Constellation :
Important details of family member:
Home Atmosphere and Influence :
 Social Position of family :

4. Personal History
Birth :
Mile stones :
Schooling :
Occupational History :
Menstrual History :
Sexual History and Practices :
Sexual Identity :
Marital History :
Habits :
Previous medical & mental illness :

5. Pre-Morbid Personality
Interpersonal Relationship :

Use of Leisure time :

Predominant Mood :

Attitude to self and others :

Attitude to work and responsibility :

Religious belief & moral attitude :

 Fantasy life :

Habits :

6. History of Present Illness

Present precipitating factors :

Causes of illness :

When and what happened :

Sequence of symptoms :

PSYCHIATRIC DIAGNOSIS
PSYCHOLOGICAL EVALUATION (PSYCHODIAGNOSTICS)

PSYCHOSOCIAL DIAGNOSIS
Brief Picture of the patient and Illness

The Cause

Affect

TREATMENT PLAN

TREATMENT PROCEDURE

EVALUATION BASED OF TREATMENT PLAN