CASE HISTORY SCHEDULE
SOCIODEMOGRAPHIC DETAILSName:
Age:
Sex:
Educational Qualification:
Occupation:
Residence:
Address:
Referral -
Informants-
Source:
Reason:
BACKGROUND INFORMATION-
Presence of any psychiatric Illness in the familypsychiatric illness /suicide / Epilepsy /substance dependence
Family HistoryFather
Mother
Age
Living/Deceased
Relationship with patient
Expressed EmotionWarmth / Hostility / critical comments/ over involvement/ positive remarks.
Birth & Developmental History-
Childhood Disorder (if any)-
Academic HistoryI. Last grade completed:
II. Academic Performance:
III. School complaint:
OccupationI. Working/Non-working
II. Work Record: Average /Below Average /Falling
III. Work position: Rising/ static/ Falling
IV. Has the patient been working in the past 1 year or least 6 Months:
Yes/No
Marital HistoryI.
II.
III.
IV.
V.
Age of and types of Marriage:
Marital Adjustment:
Details of spouse:
Sexual adjustment
Extra marital relation
Habits and Addiction: (If any)
Premorbid Personality:
I.
II.
III.
IV.
V.
Attitude towards self:
Sociability:
Predominant mood:
Adjustment:
Hobbies and Interest: