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PRO FORMA FOR TAKING CLIENT HISTORY

CASE HISTORY
I. ADMISSION
a. Client number/ admission registration number-
b. Name of informant -
c. Relation with client-
d. Referred by –
e. Reason of referral-
f. Date of admission-
g. Client’s case history taken by-
II. CLIENT’S SOCIO-DEMOGRAPHIC DETAILS
a. Name of client-
b. Parent’s name/ spouse name-
c. Age-
d. Sex-
e. Language- Mother language:-
Other Language:-
f. Address-
g. Religion-
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h. Habitat ( Urban/ semi urban/rural)-

i. Marital status-
(Single/Married/Divorced/Separated/Widow/Others)
j. Occupation-
k. Education-
l. Informant relationship with client-
III. CHIEF COMPLAINTS/ PROBLEM DURING ADMISSION-
1. Client’s problem…………………………………….
2. Nature of the problem and present severity of the
symptoms……………………………………………………………………………………………………………………………
……………………........
3. Systematic enquiry about other relevant problems and
symptoms……………………………………………………………………………………………………………………………
………………………....
4. Onset and course of symptoms and problems……………………………………………………....

IV. History of client’s present problems( Psychosocial)

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1. (Client should be given enough time so that he can talk without hesitation about his problems in his own word.)
a. Duration of total illness/problems-
b. Current: episode/ exacerbation-
c. Course: continuous/episodic/unclear/fluctuating/deteriorating/
Improving/precipitating factors (describe)……………………………………………………….

2. Details of the nature of the problem and symptoms

……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………..
3. Systematic enquiry about other relevant problems and symptoms
……………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………….
4. Onset and course of symptoms and problems.
……………………………………………………………………………………………………………………

V. Family history
1. Father-
a. Name-
b. Age-
c. Occupation-
d. Personality and relationship with client-
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2. Mother-
a. Name-
b. Age-
c. Occupation-
d. Personality and relationship with client-

3. Siblings-
a. Name-
b. Age-
c. Occupation-
d. Personality and relationship with client-

4. Social position of family-

5. Atmosphere/ environment of home-
………………………………………………………………………………………………………….......

6. Family history of mental illness (Absent/ Present Mild, Moderate, Severe)

……………………………………………….…….………………………………………………………
7. If present
……………………………………………………....
8. Intervention received (yes/ no)…………………….
9. Outcome…………………………………………….
VI. Past history of problem/ illness
 Previous history should be collected from the prenatal period till symptoms presentations.
 Describe each episode briefly, with onset, major features, course and duration, intervention level of recovery.
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 Psychiatric illness………………………
 Medical illness…………………………
VII. Personal history
1. Birth history-
2. Early development-
3. Childhood-
4. Schooling and education (Schooling and higher education- age of starting school, level of education, performance, relation with teac
class mates, peer groups)
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………..
5. Occupation history-
6. Obstetrical-
7. Marital history (Age of marriage, marital adjustment, if any)-
……………………………………………………………………………………………………………………………………………
………………………………………..
8. Sexual history((Premarital, extramarital)-
9. Children (How many children, sex, maladjustment, specify the reason)-
10. Family type and environment-
11. Social circumstances (Harsh up bringing)-
12. Separation; broken home, over protection etc.-
13. Physical and mental illness-
14. Emotional problems-
15. Forensic history-
O. Past Psychiatric History
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1. Frequency of occurrence, month, year, season, and treatment.

……………………………………………………………………………………………………………………………………………
………………………………………………………………………………………
P. History of Substance Abuse : If present
…………………………………………………………………………………………………………………………………….
q. Premorbid personality
1.
2.
 Frequency of occurrence, month, year, season, and treatment.
 History of Substance Abuse etc.: If present.
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