CASE HISTORY FORMAT

A. Client’s Profile – Identification Data

● Name:
● Client Code/ Unique Identification Code:
● Age (Date of Birth): Sex:
● Marital Status:
Unmarried Married Divorced Widowed
● Address:
● Father’s Name/Spouse’s Name:
● Mother tongue:
● Languages known:
● Educational Qualification:
● Occupation:
● Family Income (annual):
● Religion: Nationality:
● Identification marks (minimum two):

B. Details of the Informants

Informant 1
● Name:
● Relationship with the client:
● Duration of relationship:
Informant 2
● Name:
● Relationship with the client:
● Duration of relationship:

C. Reasons for Referral/ Purpose of Visit

● Why has the client been referred and what is the purpose of the visit?
● Letter of Referral

D. Presenting Chief Complaints (The present complaints to be written in chronological order; the
most impressing or important factor/complaint to be mentioned).

E. History of Present Illness (A detailed history of the present illness from onset to the time of
consultation in a chronological order of its evolution and its course).
● When was the client last entirely well?
● Onset
o Abrupt (less than 48 hours)
o Acute (few hours to two weeks)
o Sub-acute (few weeks)
 o Insidious (few weeks to a few months)
o Chronis (several months to years)
● Duration (of the present illness)
● Provocative/alleviative factors/variables (seasonal/diurnal)
● Course
o Continuous
o Fluctuating
o Episodic (episodes of symptoms with periods of normalcy)
o Unclear (Fluctuating/ Deteriorating/ Improving)
● Precipitating Factors (The triggering factor should be mentioned. It may be physical or may be
the consequence of either illness or any other event that just preceded the illness. Mention
detailed accounts about the factors should be given).
● Baseline
● Associated Disturbances (impairment in other areas of functioning such as sleep, weight
changes, sexual life, social life and occupation. Also mention about any cardiovascular changes
such as shortness of breath especially on exertion, fainting or syncope, sweating on feeding,
chest pain, palpitation, edema, cyanosis, squatting etc.)
● Negative History (related to organic/ other physical problems such as vomiting, pain, fever,
headache, memory disturbances, cardiovascular disturbances, pervasive mood changes,
substance misuse, and confusion. Also, if fallen down and injured, and side effects of a drug
medication. Mention quality of each such disturbances: such as composition of vomit, kind and
site of pain, etc. Also mention the quality of same such as amount and number of times
vomiting, degree of fever, number of headaches, etc.).
● Treatment (if any) for any of the above mentioned associated disturbances and negative history.

F. Systematic Inquiry
● Respiratory system (sore throat, earache, cough, chest infection, history of aspiration,
hemoptysis)
● Gastrointestinal system (abdominal pain, vomiting, jaundice, diarrhea/constipation, blood in
stool)
● CNS (syncope/dizziness, fits/seizures, headache, visual problems, numbness, unpleasant
sensations, weakness, frequent falls, incontinence)
● Genitourinary system (stream, dysuria, frequency of urination, incontinence, enuresis/nocturia,
hematuria)
● Rheumatological system (limp, joint swelling, hair loss, skin rash, dry mouth/mouth ulcers, dry or
sore eyes, cold extremities)

G. Past History
1. Birth History (important in neonatal, genetic or developmental case)
● Antenatal History
o Health and nutritional status of mother during pregnancy
o Illness during pregnancy (HTN, DM, Pre-eclampsia, antepartum, hemorrhage)
o Infections during pregnancy (T.B., Rubella etc.)
 o Drug (iron, multivitamins etc.: dose and duration, given at which point in pregnancy;
allergic drug reactions)
o X-ray
o TT (maternal vaccination against Tetanus)
o Post Obstetric (problems in past pregnancy, stillbirth, abortion, birth weight of
previous child/children, prematurity, blood transfusions, type of delivery of pervious
child/children)
o Complications
● Natal History
o Place of birth (hospital/home)
o Gestation time (length)
o Labour time (duration)
o Presentation and type of delivery (SVP, forceps, vacuum extraction or C-section)
o Sedatives/analgesic during labour
o Complications (abnormal bleeding)
● Post-natal History
o 1st cry (immediate, cyanosed, apneic)
o Basic problems (need for resuscitation, problems with respiration,
sucking/swallowing)
o Birth weight
o Birth injury
o Convulsions, cyanosis, jaundice, fever, rash
o Procedures (exchange transfusion, umbilical artery cauterization, drugs)
2. Feeding History (significant in children below 2 years: anemic or malnourished)
● Onset of feeding (after how many hours)
● Type of feeding
● Supplements (vitamins, iron)
● Weaning (when, what, amount, frequency)
3. Immunization
● Types of vaccination given
● Age at which given and by whom
● Doses and adverse effects
4. Developmental History (achieving age of various milestones; normal or delayed should be
mentioned)
● Smiling
● Sit
● Crawl
● Stand
● Walk
● Talk
● Control of bladder and bowel
● Eruption of teeth

#Compared with normal age-appropriate development.

5. Past Medical History
● Life Chart
History of similar and significant illness (physical or emotional disturbance) in the past, its
precipitating causes, duration, interval period, symptoms of each episode [duration]).
● Treatment History
Treatment for the above mentioned illness (medication, dosage, duration, presence of side
effects, regular follow-ups, resistance to treatment).

H. Family History (psychiatric/medical illness)

a. Genogram (draw the tree for three generations on both sides in case of genetic important,
age and cause of death (if any) of the family members should be noted)
b. Age of mother and father, and number of years of their marriage (also mentioning the age of
the mother when the child was born)
c. Type of family (nuclear/joint/specify if others)
d. Anomalous family situation: Yes/No (step parents or adoption status)
e. Socio-economic status (lower/middle/upper)
o Parents education and occupation
o House (made of, size, etc.)
o Cleanliness and general hygienic conditions at home
o Any pets at home
f. Role functions
g. Child rearing practices
h. Communication pattern among family members and interpersonal relationships
(circumstances and environment at home should be noted)
i. Leader/Head of the family (nominal and functional)
j. History of illness in family
o Psychiatric (similar illness, other illnesses, major behavioural problems such as
delinquency, personality problems, suicide/suicidal attempts, epilepsy, substance
abuse, mental retardation, sexually deviant behavior)
o Medical (especially hereditary)
k. Attitude of family member’s towards the client’s illness:
l. Cultural and religious values of the family
m. Social support system

I. Personal and Social History

a. Childhood History (behaviour during childhood to be mentioned, normal/abnormal/any
specific trauma/convulsions/fever/any other illness.
o Parental lack: Yes/No (Dead/Absent for more than a year/habitually away from
home)
o Home atmosphere during childhood: Satisfactory/Unsatisfactory
o Behavioural and emotional problems (any particular habits, sleep disturbances, nail
biting, thumb sucking, tics, mannerisms, enuresis, sleep walking, temper tantrums,
stammering, morbid fears/phobias, night ???. Also conduct behaviours such as
 frequent fights, truancy, bullying/bullied, stealing, gang activities should be noted
along with its occurrence).
o Educational and School History (age of beginning and finishing formal education,
academic and extra-curricular achievements, interest in students, behaviour, and
relationship with peers, especially of opposite sex and teachers, any school phobia,
non-attendance/regularity, any learning difficulties, reasons for termination of
studies [if occurs prematurely] should be noted).
o Play History (which game was played and at what stage, with whom and where)
o Physical illness during childhood (special enquiry regarding Epilepsy, Meningitis and
Encephalitis)

b. Puberty
o Age of menarche and reaction to it (for females)
o Regularity and duration of menses (for females)
o Length of each menstrual cycle (for females)
o Last menstrual period (for females)
o Any abnormalities in menstrual cycle (for females)
o Age of menopause
o Age of appearance of secondary sexual characteristics (in both males and females;
mention the time of facial hair growth etc.)
o Nocturnal emission (in males)
o Masturbation
o Anxiety related to puberty to be mentioned.

c. Occupational History
o Age of starting work
o Jobs held in chronological order
o Reasons for changing jobs
o Job satisfaction
o Work environment
o Relationship with authorities, colleagues/peers and subordinates
o Appropriateness of job to the education and family background
o Present income
o Work shift
o Intervals of rest breaks during a work day

d. Sexual and Marital History

o Information about sexual information (how acquired, of what kind, how received,
adequacy of knowledge, attitude towards opposite sex, and same sex
normal/abnormal).
o Masturbation (age of starting, frequency, guilt/attitude if any)
o Sexual experience (homo/hetero/pre or extra-marital/preferences)
o Adolescent sexual activity (if any)
o Gender Identity Disorder (if any)
 o Duration of marriage(s) and/or relationship(s)
o The duration for which the partner was known before marriage
o Kind of marriage (arranged by parents with/without consent, self-choice, parental
consent)
o Number of marriage, divorces or separations
o Role in marriage
o Interpersonal and sexual relations
o Contraceptive measures used
o Sexual satisfaction
o Mode and frequency of sexual intercourse
o Psychosexual dysfunction (if any)

e. Alcohol and Substance History

o Eating fads/patterns
o Sleeping patterns
o Excretory functions
o Alcohol consumption (duration, amount and frequency)
o Tobacco consumption (duration, amount and frequency)
o Any drug addiction (if any, then duration, amount and frequency)
o Self-medication with drug

J. Pre-morbid Personality
● Social relation and Interpersonal relationships (The family attachment/dependence to
friends/groups/societies/clubs, to work and workmates; leader, aggressive, follower, organizer,
ambitious, submissive, adjustable, independent, introverted/extroverted, insensitive/sensitive to
criticisms, trusting or suspicious/jealous, emotionally controlled or quick tempered irritable,
tolerant, adaptive, or rigid, etc.)
● Intellectual activities (hobbies, interests, books, plays, pictures, memory observations)
● Mood (bright and cheerful or despondent, worrying or placid, stung or calm/relaxed, optimistic
or pessimistic, self-depreciative or satisfied, mood stable/unstable)
● Attitude to work and responsibility (welcomes or worried by responsibility, makes decisions
easily or with difficulty, haphazard or methodological/meticulous, right or flexible, cautious,
foresight/impulsive, preserving or determined or easily bored and discouraged)
● Energy and Initiativeness (lethargic or sluggish, irregular fluctuations in energy levels)
● Fantasy Life (frequency or content of day dreaming)
● Habits

K. Summary