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380 views6 pages

Case History Format

Uploaded by

zebazafar01102003
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Angel Clinic mind & body holistic centre

CASE HISTORY FORMAT

1. IDENTIFICATION DATA

Name:

Age:

Gender:

Educational Qualifications:

Occupation:

Marital Status:

Socio-economic status:

Living condition:

Languages known:

Religion:

Nationality:

Place of Residence:

Date of assessment:

Primary reasons for seeking help: health/psychiatric/job/ family/legal.

2. INFORMANTS: (Details of informants, including their relationship to patient)

3. PRESENTING COMPLAINTS (from patient and informant)

4. CHIEF COMPLAINTS (In chronological order with Duration)

Age of first onset of use the substance

Course:

Episode:
Progress:

Treatment:

5. DRUG USE HISTORY/ HISTORY OF PRESENT ILLNESS:

(a) Age of initiation of substance, reasons for initiation and continuing use, acute effects

(b) Age at which regular daily use started, progression of use over time

(c) Change effects experienced over time (tolerance)

(d) Ask when withdrawals first experienced, nature and severity of withdrawals,
complicated withdrawals (delirium, seizures etc , if any)

(e) Craving to take substance

(f) Pattern and frequency of use: (Ask about the usual dose current (past 1 month)
consumption, maximum dose and last dose)

6. HIGH RISK BEHAVIOUR

(For IDUs): Needle use practices:

Sharing of needles

Sharing of syringes, cotton, vials, or other paraphernalia

Cleaning practices

Sites of injection use iv/im; any dangerous sites of use

Reuse of needles and syringes

Places where injections are taken

Needle site complications

(For all substance users): Unsafe sexual practices:

Multiple partners, sex with CSW; Anal sex; barrier methods

Knowledge of HIV/AIDS
7. PERIODS OF ABSTINENCE AND TREATMENT, IF ANY

(a) Number/duration of abstinent attempts, reasons for seeking abstinence

(b) Nature/type of treatment sought, duration of treatment

(c) Level of functioning during abstinence

(d) Use/escalation of any other substance during abstinence


(e) Reasons/circumstances of relapse

8. PAST HISTORY: Physical and psychiatric illness history

9. FAMILY HISTORY:

Family history of drug use, psychiatric illness


Family’s Attitude towards Illness

Current living arrangements

Social support

Reason for seeking treatment currently

10. PERSONAL HISTORY:

 Developmental History (this heading will include prenatal, natal and post-natal
history i.e birth complications, nature of delivery, developmental milestones etc)
 Childhood history :(presence of early childhood disorders)
 Home environment: (living Conditions and who all in family, rooms, income,
earning members etc)
 Educational History (will also include play behavior)
 Vocational History
 Occupational History
 Marital History and Sexual

11.TEMPERAMENT/PREMORBIDTEMPERAMENT/PREMORBID
PERSONALITY (CHOOSE THE HEADING APPLICABLE TO YOUR CASE)

Premorbid Personality:
Social relations:
Intellectual activities: (hobbies and interest etc)
Mood: (bright, cheerful and relaxed etc.)
Character:

I. Attitude to work and responsibilities

II. Interpersonal relationships:

III. Standards in moral, religious, social and health matters:

IV. Energy, initiative:

V. Fantasy life:
VI. Habits:

Impression:

12. Intake: Examination.

(Detailed physical examination: illnesses & complications. assessment of withdrawal.


Physical examination can point to evidence of drug use e.g. injection marks or inhalant
stains. The evidence of physical harm as a result of drug use should be looked for).

13. Behavioural Observation/Mental Status Examination

General appearance and behaviour


Attitude and relationship towards examiner
Motor Behaviour (Posture, Reactive movements, Grooming movements, Expressive
movements, pathological movements and goal directed)
Insanity of the movements
Speech (Rate,Tone,Volume,Reaction)

Consciousness and Orientation: (Time, Place, Person)

Higher Cognitive Functions:


Attention and Concentration:

Memory

 Immediate Memory
 Recent Memory
 Remote Memory
Abstract thinking:

General fund of Knowledge:

Athematic Calculations:

Intelligence:

Affect:

Subjective-
Objective-

Impression-

Thought – Stream:

Form:

Possession:

Content:

Perceptual Disorders: (Hallucinations and Illusions)

Judgment – Test, Social, Personal

Insight:

Motivation: Assessment of patient’s motivation is very important. A patient can be


considered to have a good motivation if there is

• Acceptance of the problems associated with drug use

• A strong desire to quit

• A high ‘internal locus of control’ (takes responsibility for own behaviour and actions
rather than blaming external factors)

14.Diagnostic Formulation:

Diagnosis should include the following:

 Primary drug status


 Secondary drug status
 Physical co-morbidity
 Psychological morbidity
 Psychosocial issues

(Based on the information obtained during the interview, it will be possible to summarize
the patient’s problem and understand whether he has a pattern of harmful use or
dependence syndrome (addiction) as per ICD-10 (International Classification of Diseases,
10th edition).

Provisional Diagnosis:
Points in favour:

Points in against:

Differential diagnosis:

Assessments Administered

S. No. Name of Test Rationale

Test Behavior:

Test Findings:

Summary:

Impression:

Prognostic Factors

Poor:

Good:

Management Plan

 Short term Goals


 Long Term Goals

Examiner Supervisor

Signature Signature

Date Date

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