CASE RECORD FORMAT

Department of Clinical Psychology

Institute of Psychiatry
7, D. L. Khan Road, Kolkata – 700025
C.R.F. No.: IOP/CP/ Dated:

IDENTIFICATION & SOCIODEMOGRAPHIC DETAILS Identification Marks

1. Name 1…………………………………………………
2. Sex/ Gender 2…………………………………………………
3. Age
4. Address (Local) -

Telephone No.
Address (Permanent) -

Telephone No.
5. Marital Status
6. Mother Tongue
7. Education
8. Occupation
9. Religion & Caste
10. Resedence Rural Urban Suburban
11. Family Type: Nuclear Joint Extended
12. Family Size: Adults: Children (below 18 years):
13. Income
a) Income Sources I. II. III
b) Family Income:
c) Patient’s Income:

SOURCE OF REFERRAL
REASONS FOR REFERRAL

ICD Code (Provisional Diagnosis)-

ICD Code (Final Diagnosis)-

Case Notes Taken By

Discussed with:

1
 PATIENT’S REPORT
Reliability: Satisfactory/ Unsatisfactory
Adequacy of information: Adequate/ Inadequate

PRESENTING COMPLAINTS (In Chronological order with Duration)

HISTORY OF PRESENT ILLNESS (By Self): (Spontaneous narrative account, Chronological Sequence, Psychosocial & functional impact
of symptoms, any precipitating, perpetuating/ limiting/ modifying factors, relevant negative history)

● Stressors/ Precipitating factors (if any): over the year and prior to onset of illness
(Enquire for stressful events involving personal/ occupational/ interpersonal areas including life events, their perceived impact according to
patient)

● Mode of Onset:
Sudden/ Abrupt (Within 48 Hours) Acute (Within 2 weeks) Insidious (> 2 weeks) Not known

● Course: Continuous Episodic Not Known

● Progress: Status Quo Deteriorating Improving Fluctuating

2
● Biological Functioning (Any Change)
Sleep: Unchanged Increased Decreased
(Describe)
Appetite: Unchanged Increased Decreased
Sexual Interest & Activity: Unchanged Increased Decreased
Energy: Unchanged Increased Decreased

● Negative History

3
 INFORMANT’S REPORT
1. Name of the Informant
i.
ii.
2. Relationship with the client

3. Duration of relationship with the patient

4. Duration and continuity of stay with the patient
5. Consistency & Corroborativeness of information provided
6. Reliability & Adequacy of information provided

PRESENTING COMPLAINTS (In Chronological order with Duration)

HISTORY OF PRESENT ILLNESS (By Informant): (Spontaneous narrative account, Chronological Sequence, Psychosocial & functional
impact of symptoms, any precipitating, perpetuating/ limiting/ modifying factors, relevant negative history)

● Stressors/ Precipitating factors (if any): over the year and prior to onset of illness
(Enquire for stressful events involving personal/ occupational/ interpersonal areas including life events, their perceived impact according to
informants)

● Mode of Onset:
Sudden/ Abrupt (Within 48 Hours) Acute (Within 2 weeks) Insidious (> 2 weeks) Not known

● Course: Continuous Episodic Not Known

● Progress: Status Quo Deteriorating Improving Fluctuating

4
● Biological Functioning (Any Change)
Sleep: Unchanged Increased Decreased
(Describe)
Appetite: Unchanged Increased Decreased
Sexual Interest & Activity: Unchanged Increased Decreased
Energy: Unchanged Increased Decreased

● Negative History

5
TREATMENT HISTORY(Nature of medical and nonmedical treatment received during the current course, its duration, response, side effects)

PAST ILLNESS (Symptoms, Diagnosis, Treatment, Outcome)

1. Medical

2. Psychiatric (Chronologically past episodes and hospitalization, symptoms, treatment received, response to treatment, compliance,
reasons for poor compliance if applicable, number of episodes, probable diagnosis)

FAMILY HISTORY
(Enquire for consanguinity between parents, whether living of dead, age of death and cause, education, occupation, attitude towards patients)
1. Family Tree (Family of origin Three Generation)

2. Family Interaction Pattern

i. Communication
ii. Leadership
iii. Decision Making
iv. Role
v. Family Rituals
vi. Cohesiveness
vii. Family Burden
viii. Expressed Emotion:
a. Warmth b. Hostility c. Critical Comments
d. Emotional Over Involvement e. Reinforcement

3. Family History of Psychiatric Illness / Retardation / Suicide / Substance Dependence / Epilepsy/ odd
personalities/ dementia/ hypertension/ diabetes

6
PERSONAL HISTORY
1. Birth & Developmental History
a. Type of Birth
b. Birth Complications
c. Milestones

2. Childhood Disorders
Thumb sucking/ Bed wetting/ Night Terrors/ Sleep walking/ Stammering/ School phobia/ Phobia/ Nail biting/ Truancy/ Delinquency/ Impulsivity/
Overactivity/ Eating difficulty/ Temper tantrums/ Convulsions/ Recurrent Febrile Illness/ Failure to thrive etc .

3. Parents & Home atmosphere in childhood & adolescence

(Including parental attitude toward the child and each other, child’s attitude toward parents, attitude of significant others, any parental lack)

Home atmosphere: (Congenial/ Broken home/ Disturbing)

4. Scholastic & Extracurricular Activities

a. Highest grade completed
b. Academic performance
c. Reason for Discontinuation
d. Peer relationships
e. Any disciplinary problems
f. Hobbies, Interests & extracurricular activities
5. Interpersonal Relations & Social Activities

6. Occupational history
a. Started working at the age
b. Any change of jobs
c. Reasons for change
d. Duration of Present job
e. Nature of job
f. Has the patient been working in the past 1 year or at least 6 months: Yes / No
g. Work Record: Good / Satisfactory / Unsatisfactory
h. Work Position: Rising / Static / Falling
7. Menstrual history

7
 Menarche Date of L.M.P. Periods (Regular/ Irregular)
Duration
Any associated physical / psychological symptoms:
Any amenorrhea currently
Age at menopause
Any related symptoms
8. Sexual History (Knowledge, Attitude towards sex, practices. Enquire for sexual abuse, STD and other sexual deviance)

9. Marital History (Age & type of marriage, Parental consent, Details of spouse including personality, Marital Adjustment, sharing
responsibilities & decision making, Sexual adequacy/ adjustment, Extra marital relation. Methods of contraception, living arrangement,
relationship with other family members)

Family of Procreation

10. Habits & Addictions (Sleep pattern, food habit, any habitual behaviours and use of substance)

11. Legal History

12. Premorbid Personality (Attitude towards Self including strength and weakness, Sociability, Responsibility taking and
leisures, Predominant Mood, Attitude towards criticism, Character, Moral values, Adjustment, Hobbies & Interest)

8
 MENTAL STATUS EXAMINATION
Consciousness:

1. General Appearance & Behaviour

a. Appearance: Well kempt & tidy / Unkempt & untidy / Overly made up / Perplexed / Sickly
b. Body build:
c. Hair: Well groomed / Negligent / Disheveled
d. Contact with the surroundings: Present / Partial / Absent
e. Eye Contact: Present / Partial / Absent
f. Rapport: Easily established/ Established with difficulty/ Not possible
g. Attitude Towards Examiner: Cooperative / Defensive / Guarded / Evasive / Suspicious / Hostile / Ingratiating /
Playful / Exhibitionistic/ Seductive / Distractible / Uncooperative
Comments-

h. Motor Behaviour:
Hyperactive/ Restless / Awkward / Gestures / Self injurious/ Retarded / Tics / Mannerisms / Stereotypes /
Hallucinatory behaviour / Touching Examiner / Utilization behaviour / Aggressive / Preoccupied / Silly Smiling / Waxy
Flexibility / Negativism / Ambitendency / Rigidity / Automatic Obedience etc.
Comments-

2. Speech
a. Intensity / Tone: Soft/ Audible/ Loud
b. Reaction Time to Stimulus: Normal / Shortened/ Delayed
c. Speed: Normal / Very slow / Rapid / Pressure of speech
d. Prosody / Tempo: Normal Fluctuations / Monotonous
e. Ease of Speech: Spontaneous /Hesitant /Mute /Slurring/ Stuttering/ Whispering/ Muttering/ Speaks only when
questioned
f. Productivity / Volume: Normal/ Overabundant/ Poverty of speech/ Poverty of content
g. Relevant / Irrelevant to the Context / Situation
h. Coherent / Incoherent
i. Goal Direction: Goal directed / Non-Goal Directed/ Circumstantial/ Tangential
Sample speech:

3. Volition
9
 a. Made Phenomenon: Made Affect Made Impulse Made act
b. Somatic Passivity
c. Echolalia/ Echopraxia/ Other catatonic features

4. Cognitive Functions
a. Orientation: Time Place Person Date Day Month Year

b. Attention & Concentration: (Test given and response)

Easily aroused and sustained/ Easy to arouse but not sustained/ Difficult to arouse and not sustained/ Difficult to
arouse but sustained
c. Memory:
Remote memory (Personal and Impersonal):

Recent memory:

Immediate memory: DF: DB: Word recall:

d. Abstraction:
Similarities-

Proverbs-

Concrete Functional Conceptual Over abstraction

e. General Intelligence:
Information-

Calculation-

Comprehension-

Vocabulary-

Comment:

f. Judgement: Personal Social Test

Poor / Satisfactory / Intact Poor / Satisfactory / Intact Poor / Satisfactory / Intact

10
 g. Lobe Function: (clock drawing, alternate pattern drawing, alternate sequence etc.)

5. Mood / Affect
i. Subjective (patient’s own narrative account)
Diurnal Variation: No/ Yes* (*Worse in morning/ evening/ night)

ii. Objective (Euthymic/ Anxious/ Panicky/ Fearful/ Depressed/ Weeping spell/ Irritable/ Enraged/ Cheerful/
Euphoric/ Elated/ La-belle Indifference/ Blunted/ Flat)

iii. Depth: Normal Shallow

iv. Range: Adequate Restricted
v. Stability: Stable Labile Incontinence
vi. Appropriate to the Situation/ Thought
vii. Communicability
viii. Reactivity to the Stimulus

6. Thought
a. Stream
i. Normal
ii. Retarded
a. Thought Blocking
b. Circumstantiality
c. Perseveration
iii. Accelerated
a. Flight of Ideas
b. Prolixity
c. Pressure of Speech

b. Form
Normal/ Poverty of content/ Derailment / Loosening of Associations/ Neologisms/ Word Approximations/ Word
Salad / Incoherence/ Clang/ Illogicality/ Tangentiality/ Distractible Speech/ Perseveration/ Circumstantiality/ Loss
of Goal/ Self Reference
Sample Talk:

c. Possession
i. Obsession & Compulsion

11
 ii. Thought Alienation:
Thought Insertion Thought Broadcasting Thought Withdrawal
Sample Talk:

d. Content
i. Religious preoccupation/ Philosophical preoccupation/ Sex preoccupation/ Somatic preoccupation/
Preoccupation with precipitating factors/ Excess day dreaming etc.

ii. Phobias

iii. Ideas of hopelessness/ helplessness/ worthlessness/ Ideas of guilt/ Death wishes/ Suicidal ideas/ Homicidal
ideas/ Hypochondriacal ideas

iv. Ideas of reference, persecution, grandiosity, infidelity etc./ Overvalued ideas

v. Delusions
a. Primary Delusions
b. Secondary Delusions
c. Systematized / Non systematized
d. Mood Congruent / Mood Incongruent
e. Types
Sample Talk:

7. Perception
i. Projection: External / Internal Illusion / Hallucination
ii. Modality
iii. Content

iv. Response to content

v. Frequency & Diurnal pattern
vi. Thought Echo / Second Person / Third Person (Intensity, clarity, vividness & insight)
Describe:

vii. Others (Extracampine/ Autoscopic/ Reflex/ Functional/ Pseudohallucinations etc.)

8. Other Phenomena (Depersonalization, Derealization, Déjà vu, Jamais vu, Retrospective Falsification, Confabulation)

9. Insight:
Grade I (Complete Denial of Illness)

12
 Grade II (Slight Awareness of being sick but denying at the same time)
Grade III (Awareness of being sick but blaming it on external factors)
Grade IV (Awareness that illness is due to something unknown in the patient)
Grade V (Intellectual Insight)
Grade VI (Emotional Insight)
Sample Talk:

Diagnostic Formulation

10. Provisional Diagnosis in Multiaxial Format

Points in Favour Points Against

11. Differential Diagnosis

Points in Favour Points Against
i.

ii.

12. Prognostic Factors

13
13. Management Plan
i.

ii.

Signature: Date:

14