Socio-Demographic Details
CP: No:
Name:
Age:
DOB
Date of evaluation:
Place of residence:
Educational Status
Address:
Source of referral:
Information gathered from:
a)
b)
Reliability and Adequacy of information:
Identification marks of the patients
1.
2.
Presenting Complaints
History of Present Illness
c)
Sex:
History of Past Illness (Medical / Psychiatric / Neurological)
Family History
Diagnosis :
Personal History
Significant Prenatal History
Significant perinatal factors.
Developmental History
Motor Development:
Language Development:
Self Help Skills
Social Relationships:
Peer relationship –
a) Special friends:
b) Groups:
c) Solitary Play:
d) Co-operative play:
e) Imaginative Play:
Quality of peer relationships
f) Cordial:
g) Confiding:
h) Distant:
Parenting (Mention Father and Mother Separately)
i) Permissive, Restrictive, Accommodating:
ii) Communication:
iii)
Criticism, hostility, rejection:
iv)Encouraging, Supportive, nourishing:
Any other relevant information
Behavior problems
Schooling history:
Habits interests and talents
Sexual history
Physical Status:
General Temperament and Personality Attributes
Activity level.
Rhythmicity (Regularity) of biological functions:
Approach or avoidance:
Adaptability:
Threshold of responsiveness:
Intensity of reaction.
Quality of mood.
Distractibility
Persistence Qualitative Analysis: Easy /Difficult / Slow to Warm temperament.
Psychological Evaluation
Mental Status Examination
Initial Observation
Attention and Concentration
Activity Level
Motor behavior
Speech and language Ability
Cognitive functions (Orientation, Memory, General fund of information and General intelligence)
Mood and affect
Thought processes
Perception
Child’s version of the problem
3 wish test
Tasks given to the child (Specify) and comments thereon
Any other observation or comments such as play room observation.