CASE HISTORY

Case No. Date:_________/__________20

PERSONAL HISTORY

Name: _______________________________________________________________

Address: _____________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Mobile: Email:

Birth date:______/________/_________ Age:

Gender: Female/Male Marital Status: Unmarried/Married

Education: Language:

Occupation:

If Married:

Spouse Name: _________________________________________________________

Spouse Education: Spouse Age:

Relationship of client with her/his spouse:

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 FAMILY HISTORY

Parents Name: 1.
2.

Parents Education: 1. Parents Age: 1.

2. 2.

Siblings Name: 1.
2.

Siblings Education: 1. Siblings Age: 1.

2. 2.

Family Type: Joint/Nuclear

No. of Family Members:

Description of Family Members:

Childhood History:

Psychosexual History:
1. Source of teenage sexual knowledge:

2. Love affairs:

3. Any sexual harassment or Trauma

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 MEDICAL HISTORY

Present Medical History

1. Description of Problem

2. Time and duration of Problem

3. Detail of medical or other treatment

Past Medical History

1. Description of Problem

2. Time and duration of Problem

3. Detail of medical or other treatment

Psychological or Psycho-somatic Disorder

1. Description of Disorder

2. Time and duration of Disorder

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 3. DSM or ICD 10 criteria met

4. Detail of Psychotherapy or medical treatment

a. Name of Psychotherapy

b. No. of session taken

c. Cause of termination

Family Medical History

1. Name and relation

2. Description of Problem

Time and duration of Problem

3. Detail of medical or treatment

Hunger/diet:
More/less/proportionate

Sleep:
 Time of sleeping:
 Quality of sleep: normal/disturbed
 Problems with sleep: dreams/snoring/not getting sleep/early morning
awakening/getting sleep for few hours/getting up in midnight

Addiction:

Nature:

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Routine:

Interests/hobbies:

Conclusion

Signature

Identification of the problem:

Any stressors or psychological causes identified:

Goals:

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