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P .G. Diploma in Guidance & CounsellingOrganized by

Ram akrishn a M ission Sikshan am and iraCollege of Teacher Education (CTE)

(A NCTE Recognized Residential Post-Graduate Autonomous College under theUniversity of Calcutta)

Belur Math, Howrah – 711 202, West Bengal 

Regn. No. ______________________________ Date: ________________

Indoor Regn. No.________________________ Refd. By______________

CASE HISTORY RECORD SHEET

1. Identifying data: 

i.   Name ………...……………………………………………..

ii.  Age ………...……………………………………………..

iii.  Sex Male Female Transgender

iv.  Education ………...…………………………………………

v.  Occupation ………...…………………………………………

vi.  Marital Status Single Married Widow Divorce

vii.  Religion : Hindu Muslim Christian Others

viii. Present Address …...……………………………………………………………………………...

………………………………………………………………………………………………………….

ix.  Permanent Address………..………………………………………………………………………

………………………………………………………………………………………………………….

x.   Name of Father / Husband ……………………………………………………………………...

xi. 

Socio-economic Status …………………………………………………………………….........

xii.  Informant’s Name: ……………………………………………………………………………..

xiii. Relation with patient: …………………………………………………………………………

xiv.  Reliability of source of information: Satisfactory / Unsatisfactory.

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2. Chief Complaint:

  Duration of Current illness:

  Mode of Onset:

 

Precipitating factors:

  Course and Progression:

3. History of Present Illness:

4. Treatment history (Current Episode):

5. Past History:

  Past Psychiatric Illness (Symptoms and Treatment):

  Past Physical Illness (Symptoms and Treatment):

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6. Personal History:

  Birth and Development:

 

Sexual and Menstrual History:

  Marital Relation:

  Habits and Addiction:

7. Family History:

8. Premorbid Personality: 

9. Mental Status Examination:

  General – Appearance and Behaviour:

  Mood:

  Affect:

  Speech:

  Volition:

  Perceptual Disturbance:

  Thought:

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  Sensorium and Cognition:

(a) Alertness and consciousness: …………………………………………………………………...  

(b) Orientation: ………………………………………………………………….............................. 

(c) Memory: …………………………………………………………………………………………  

(d) Concentration: …………………………………………………………………………………..  

(e) Language: ………………………………………………………………………………………..  (f) Abstract thinking: ………………………………………………………………………………  

(g) Fund of information and intelligence: …………………………………………………………  

(h) Impulse control: ………………………………………………………………………………...  

(i) Judgment: ………………………………………………………………………………………..

(j) Insight: …………………………………………………………………………………………...

10. Physical Examination:

11. Provisional Diagnosis:

12. Prognosis:

13. Psycho dynamic formulation:

14. Treatment suggested/ Management Plan:

_____________________________

Signature of Case Taker