CASE HISTORY RECORD

(For Children & Adolescent – Up to age of 16 years)

Department of Psychology

Hospital’s Registration No. - Date first seen at the Hospital -

Internship Guide’s Signature - C.H.R. No. - WBSU/10/C/

CASE HISTORY

SOCIO-DEMOGRAPHIC VARIABLES
Name :
Age :
Sex : Male / Female
Address :

Telephone number :
Mother Tongue :
Educational Qualification :
Occupation :
Religion :
Family Type : Nuclear / Joint / Extended
Socio Economic Background :

INFORMANTS (Name & Relationship with the client)

Reliability of Information :

REFERRAL
➢ Referral Source :
➢ Reasons for Referral :

C.H.R. for Children & Adolescent - Dept. of Psychology (WBSU) 1 out of 6

CHIEF COMPLAINTS (In chronological order with duration)

HISTORY OF PRESENT ILLNESS

NEGATIVE HISTORY

TREATMENT HISTORY

PAST HISTORY
- Medical Problems

- Psychiatric Problems

C.H.R. for Children & Adolescent - Dept. of Psychology (WBSU) 2 out of 6

FAMILY HISTORY
Three Generation Genogram (Family Tree):

Father Mother Siblings

Family History of Psychiatric Illness / Mental Retardation / Substance Dependence / Epilepsy etc

PERSONAL HISTORY
Birth & Developmental History:
a) Type of Birth

b) Birth Complications

c) Significant Prenatal factors

d) Significant Perinatal factors

e) Milestones

f) Birth Order

g) Current Developmental Status

C.H.R. for Children & Adolescent - Dept. of Psychology (WBSU) 3 out of 6

 Childhood Disorders:

School History:

Sexual History:

Addiction History:

Present Style of Living:

General Temperament & Character

BEHAVIOURAL OBSERVATION
DOMAIN FINDINGS

General
Appearance

Psychomotor
Activity

Speech

C.H.R. for Children & Adolescent - Dept. of Psychology (WBSU) 4 out of 6

 Attention & Concentration

Orientation

Memory

Cognitive
Functions
Intelligence

Judgment

Level of abstraction

Mood & Affect

Thought

Perception

Child’s version
of the problem

Three Wish
Test & Animal
Test

Any Other
Observation

C.H.R. for Children & Adolescent - Dept. of Psychology (WBSU) 5 out of 6

DIAGNOSTIC FORMULATION

Provisional Diagnosis

Differential Diagnosis/ Diagnoses

……………………………….. ………………………………….
Attended By Supervised By

Note:

C.H.R. for Children & Adolescent - Dept. of Psychology (WBSU) 6 out of 6