A COMPARITIVE STUDY ON INTERFERENCE CONTROL ,REJECTION SENSITIVITY

AND INTERACTION PATTERN IN CHILDREN WITH ATTENTION DEFICIT

HYPERACTIVITY DISORDER WITH COMORBIDITIES

Semi structured proforma for the patients

Serial No ____ O. P. D. Registration No. ________

Name__________________________ Consultant I/C____________________

Age/Sex________________________ Education_______________________

MaritalStatus___________________ Religion_________________________

Occupation_____________________ Patients income___________________

Type of family__________________ Total no. of family members_________

Address________________________________________________________

Phone no._______________________ Date of OPD Registration___________

Date of Evaluation_______________ Informants________________________

Chief Complaint__________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Onset___________ Course _________Duration_________________________

Episode__________________________________________________________

Precipitant________________________________________________________

Treatment taken__________________________________________________

______________________________________________________________
History of the Present illness

PastHistory

FamilyHistory

PersonalHistory
General Examination

Temp____________________ Pulse____________ B.P. ____________

Weight—

Clinical observations

Systemic Examination

Cardiovascular system

Respiratory system

Gastrointestinal system

Central nervous system

Mental status examination

General appearance & behaviour

Speech

Psychomotor activity
Affect

Thinking: Flow

Form

Content

Perception

Cognition: Alertness

Consciousness

Orientation- Time Y/N

Place Y/N

Person Y/N

Concentration: Intact/Impaired

Memory

Intelligence

Judgement

Insight

Date of start of treatment—

Group assigned—