Case History and Psychological Evaluation

Name: Mansi
Age:18 years 3 months
DOB: 20th Jan 2005
Sex: Female
SES:
Type of Family:
Contact No.
Source of Referral:

CHIEF COMPLAINTS/CONCERNS:
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Nature of Illness:
Onset: Acute/Chronic/Insidious
Duration:
Course: Continuous/Episodic
Progress: Improving/ Stagnant/ Worsening

GENOGRAM:

Mother: Age/Education/Occupation/Relationship/Attachment Style

Father: Age/Education/Occupation/Relationship/Attachment Style

FAMILY LIFE AND RELATIONSHIPS

Family Cohesiveness (Emotional Bonding): Disengaged/Separated/Connected/Enmeshed

Adaptability: Rigid/Structured/Flexible/Chaotic

Living Arrangements: with whom and where – Current and past

Parenting Styles: Permissive/Neglectful/Authoritative/Authoritarian

Family Atmosphere: Daily life pattern/Stressors

PERSONAL HISTORY:

Birth and Early Development:

Prenatal/Perinatal/Neonatal/Developmental Milestones
EDUCATIONAL HISTORY:

Age at 1st schooling:

Academic Performance:
Syllabus:
Expectations:
School Behavior:
Extracurricular:
Specific Learning Difficulties (if any):
Behavioral Problems (if any):
Hobbies:

TEMPERAMENT AND PERSONALITY TRAITS

Emotionality
Activity Levels
Aggression:
Sociability:
Trustworthiness:
Adaptability:
Regularity of habits:

History of Presenting Illness:

Psychiatric Examination:

Comfort Level
Cooperativeness
Rapport
Alertness and attention
Activity level
Mood
Affect
Thought process
3 wishes test