CASE HISTORY PROFORMA

 Socio-demographic information
Name Education
Date of birth Informant
Age Informant’s Reliability
Gender Source of Referral
Address
 Brief Statement about the patient’s place of living and circumstances :

 Reason for Treatment :

 Chief Complaints (even if nonsensical/non-plausible)

( ) Depressed mood ( ) Motivation
( ) Unable to enjoy activities ( ) Self-esteem
( ) Change in Sleep ( ) Peer relationships
( ) Loss of Interest ( ) Social skills
( ) Concentration/Forgetfulness ( ) Family concerns
( ) Change in Weight/Appetite ( ) Bullying - Victim
( ) Fatigue/Always tired ( ) Bullying - Bully
( ) Impulsive ( ) Educational Support
( ) Excessive energy ( ) Grief and Loss
( ) Increased Irritability ( ) Aggression
( ) Crying Spells ( ) Fighting
( ) Excessive Worrying ( ) Adjustment issues
( ) Nervous/Anxious/Panic ( ) Dramatic change in Behaviour
( ) Avoidance ( ) Self-Injury (ex: cutting)
( ) Day dreams/Fantasizes ( ) Stealing
( ) Sexual Acting out ( )Self-Image
( ) Personal Hygiene ( ) Lying
( ) Scared ( ) Defiant
( ) Hyperactive ( ) Attention-Deficit
( ) Homework Completion ( ) Other ____________________
( ) Organizational Skills

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  Specifiers :
- Onset (Abrupt, Acute, Sub-Acute, Insidious) :
- Duration :
- Course (Continuous, Episodic, Progressive) :
- Precipitating Factor :

 History of Present Problem:

 Medical History
Chest Pain/ Pressure Asthma
Headache Dizziness/Fainting
Allergies Cancer
Eczema Difficulty Hearing
Seizures/Epilepsy Nose Bleeding
Vision

 Appetite :
- Number of meals a day :
- Balanced Diet : ( ) Yes ( ) No
- Allergies :
 Sleep :
- Number of hours each night :
( ) Difficulty falling asleep
( ) Difficulty staying asleep
( ) Frequent waking

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  Family History (family tree, demographics of members, history of any mental or
physical illness, relationship between members, components of support system)

 Personal History (describe events of major significance throughout a person’s life,

highlight those that may be etiologically significant, descrive functioning over time)

- Developmental Milestones

- Childhood History (any difficulties encounteres. Ex: bedwetting)

- Adolescent History

- Educational History

- Vocational History

 Pre-morbid Personality (picture of an individual before the onset)

 Diagnostic Impression :

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  Recommendations :

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