CASE HISTORY FORM

1. GENERAL PERSONAL DATA:-

Name of Child:- Sex:-

Date of Birth:- Age:-
Registration No. & Date:-
Father’s Name: - Mother’s Name:-
Occupation (Father):- Occupation (Mother):-
Education:-
Sibling (S):-
Address:-

Telephone No. :- ( R) Mobile:-

( O)

Family Structure:-
Type:-
Status / Income per month:-

Referred by:-

Previous School:-
(if any)

2. SPECIFIC PERSONAL DATA

1) Referred problem / or set of the problem
2) History of Problem
3) Previous diagnosis:-
 4) Previous intervention:-
5) Misconceptions (if any):-
6) Language understood by the child:-
7) a. Principal care taker:-
b. Closest to:-

3. MEDICAL HISTORY (information from parents):-

1) Family History:-
(a) Consanguinity:-
(b) MR / Mental illness in family:-
(c) Seizures in family members:-
2) Pre-natal History
(a) Birth order of the child:-
(b) Age of parents when conceived:-
Mother:- Blood Group:- Rh:-
Father:- Blood Group:- Rh:-
© Abortion:- threatened / & Attempted:-
(c) Any complication during pregnancy:-
(d)