STUDENT HEALTH PROFORMA HEP/ OCAS

Basic Personal Information

Name of Student: __________________________________________
Father/Guardian Name: __________________________________________
Father/Guardian Contact No: _______________________ Age: ___________

Basic Medical History (Filled with Yes/No)

Family history of any Medical or Psychiatric illness?

Past medical/surgical history if any
History of substance abuse in Family (Drugs)
Decrease Appetite and loss of weight
History of Chronic Illness and Allergies

Overall General Physical Examination

Weight (kg)
Height (feet/inches)
Blood Pressure (high BP/low BP)
Temperature (°F)
Pulse Rate (per minute)
Respiratory Rate (per minute)
Blood Group

Overall Genaral Physical Health And Appearance (Good, Average, Poor)

COVID-19 Vaccination Status (Tick Any) (Not vaccinated, partially
vaccinated, fully vaccinated)
Any obvious structural abnormality on inspection (Yes,No)
Any superficial cuts, needle marks, or burn marks on skin (Yes, No)

General Mental Health as per Psychiatrist Assessment (Filled with Good,

Average, Poor)

General Appearance and Behaviour

Self Care
Rapport Building
Understanding of situation/response to instruction

General Mental Health (To be filled and authenticated by Institution) (Filled

with Yes/No)

Past psychiatric history, if any

History of smoking/substance abuse
Decline in academic performance
Risky behavior, vehicle accident, school fight, weapon possession
Habit of running away/missing routine classes
History of stealing, late arrival in school, sexual activities
Bad company, bullying, drug and scuffle
Isolation from positive interests/hobbies
Abrupt change in daily routine
Disturbed sleep/habit of dosing
Social media posts/other indications pointing towards drug use, tattoos,
sickers on vehicle/books
Mood swings/increased irritability
Lack of physical energy and motivation, fatigue and tiredom
Decline in self-care
Suspiciousness or other unusual behavior
Decline in socialization
Unusual protective behavior/over secretive behavior
Evidence of remains of cigarette/objects and tools used for drugs found in
personal belonging
Proceed to this or referral for this only if there is increased risk of substance
use suspected on the basic of Above-Mentioned general health profile
Employ this for confirmation if formal psychology assessment confirms the
suspicion of substance use found on screening by general health profiling.