Case History - Counselling

Socio- demographic details Date:

Name:
D.O.B.:
Age:
Sex:
Education:
Occupation:
Marital status:
Family type: Nuclear/Joint/Living alone/others
Religion:
Domicile: Rural/Urban/Sub-urban/others
Socio-economic status: Lower/Middle/Upper
Informant (s):
Contact no.:
Source of referral:
Case examiner:

Chief Complaints (In chronological order, duration) “what do you think are your
complaints/what brings you here
As per patient:

HISTORY OF PRESENT ILLNESS

Duration (since when is the illness ongoing):

Onset (how did the illness begin) Abrupt (Within 48 Hours)/Acute (Within 2 weeks)/Insidious (>
2 weeks):

Course (what is the course of illness) Continuous/Episodic/Fluctuating/Not knowing

Progress (what is the current progress of illness, has the illness improved, deteriorated etc)
Improving/Deteriorating/Static/Fluctuating

Predisposing Factor (genetic/biological basis for illness):

Precipitating Factor (maintaining factors):

Perpetuating factors (triggering events e.g. physical, pharmacological, psychosocial):

Role functioning (is the patient able to fulfil roles which he/she is in, able to do household work,
job/work etc)

Biological functioning

Sleep (what is the patient’s current sleep pattern) increased/decreased/disturbed/unchanged

Appetite (what is the patient’s current appetite) increased/decreased/disturbed/unchanged/weight

loss, constipation

Sexual functions (libido): increased/decreased/disturbed/unchanged

Personal care: self-care activities

Core Beliefs: Attitude towards self, others and world, interaction patterns and sociability, sense of
responsibility, predominant mood, attitude towards criticism, moral values, adjustment, hobbies,
interests, attitude towards substance, habits etc

Treatment history (for present illness) (has the patient taken any treatment for current chief
complaints)

Psychiatric consultation, faith healers, ayurvedic medications, physician etc. Record of any
ongoing medications, its effectiveness, complications, duration, compliance etc.
HISTORY OF PAST ILLNESS: (Medical and Psychiatric) (has the patient taken any
treatment for any medical or psychiatric illness in the past)

Duration, episodes, previous diagnosis, medications, compliance, hospitalization, symptom

stability, deficits, improvements if any.

FAMILY HISTORY (Genogram of three generations) (ask the patient about his/her family,
number of members, mental illness etc)

Consanguinity between parents, family members living-dead, H/O mental illness in the family
both paternal-maternal, treatment details, patient relationship with family, attachment styles,
overall attitude, family issues, quarrels, rituals etc.

PERSONAL HISTORY

Birth and Early Development History

Nature of delivery (normal/C-section delivery)

Antenatal, natal and post natal complications:

Developmental milestones (when did the patient start walking, talking, sitting, etc. Also mention
the year or month when developmental milestone were achieved)
Presence of childhood disorders (any childhood issues when patient was young)

Hyperactivity, attention-deficit, impulsivity, disobedience, conduct issues like lying, stealing,

eating difficulties, fears, worry, lack of self-confidence, sleep issues, temper tantrums, enuresis,
encopresis, tics, unusual habits, peer relations, relations with siblings

Home atmosphere in childhood and adolescence (home environment when patient was young or
in childhood)

Disturbed/congenial, desertion by a parent, broken home, step-parent, adopted siblings, patient’s

attitude towards parents, how parents perceive the patient

Scholastic and extracurricular activities

Age and class of entry in school, progress in studies, involvement in games, extra-curricular
activities, hobbies, interests, disciplinary problems, relations with peers and authority figures,
failure in any grade, discontinuation or drop out and its reasons, school/college change
Vocational/Occupational history

Age when started working, duration, positions held till now, current job and position, periods of
unemployment and reasons for leaving job, relations with colleagues and overall workplace
behaviour

Menstrual history

Age of achieving menarche, current menstrual cycles (regular/irregular), associated

physical/psychological problems, overall attitude regarding menstruation, details of menopause, if
relevant

Sexual and Marital History (how is the sexual functioning, frequency, married life etc)

sexual activities present/absent and attitude towards sex, age at marriage, spouse age at marriage,
parental consent for marriage, personality of spouse and spouse attitude towards sex, role
allocation between couple, sharing of responsibilities and decision making, premarital/extra-
marital relations, methods of contraception used if any
Elaborate on chief complaints: