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Visited institute: ………………………………………………………………………

………………………………………………………………………

-:] Case study [:-


Demographic details

Name :

Gender : Male [ ] Female [ ]

Date of Birth :

Age :

Religion :

Class :

Family Status : Nuclear [ ] Joint [ ]

Number of family member :

Socio Economic Status : High [ ] Low [ ] Middle [ ]

Domicile : Rural [ ] Urban [ ]

Address :

Presenting complains

As per patient

As per Informer

1
Biological history

Sleep

Energy

Food habit / Appetite

Present treatment history

Family history/ Genogram

Family interaction pattern

2
Academic history

3 wish test

Animal test

Counseling approach

Future management

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