Client Case Workup
Brain Health Clinic - Indira Gandhi Hospital
1. Socio-Demographic Data
Field
Detail
Field
Name
Reg. No.
Father’s Name
Age / DOB
Gender
[ ] M [ ] F [ ] TG
Medium of
Detail
Education
Occupation
Instr.
Mother Tongue
Religion
Nationality
Monthly
Income
Socio-econ
Blood Group
Status
Marital Status
Residence
Family Type
[ ] Nuc [ ] Jt [ ] Ext
[ ] Urb [ ] Rur [ ] Sub Contact No.
Address: ______________________________________________________________________
Referral Data

Source of Referral: __________________________

Reason for Referral: __________________________
2. Informant Details and Reliability

Informant Name: __________________________ Age: __________

Education: __________________________ Relationship to
Patient: __________________________

Duration of Relationship: __________________________

Duration & Continuity of Stay: __________________________
Reliability and Adequacy Checklist

[ ] Consistency [ ] Confirmability [ ] Credibility [ ] Constancy [ ] Adequacy

Clinical Impression: [ ] Reliable [ ] Not Reliable
3. Presenting Complaints and History of Presenting Illness
(HOPI)
Chief Complaints
Complaint Duration
Verbatim Quote (Client/Informant)
Clinical Narrative
Negative History (To rule out associated psychological disorders, organic
causes, or comorbidities)
Onset, Course, and Progress

Onset: [ ] Abrupt (<48 hrs) [ ] Acute (<2 weeks) [ ] Subacute (1–2 weeks) [ ]
Gradual (>2 weeks) [ ] Insidious

Course: [ ] Continuous [ ] Episodic [ ] Fluctuating

Progress: [ ] Improving [ ] Deteriorating [ ] Static

Total Duration of Illness: __________________________
Precipitating Factors:
6. Past and Family History
Past History:

Psychiatric: (Symptoms, Diagnosis, Treatment, Outcome, Adherence)

Medical/Surgical: (Symptoms, Diagnosis, Treatment)
Family History:

Genogram (Family Chart) :

Patient stays with parents:

Has any Siblings (if so, how many):

Consanguinity: [ ] Yes [ ] No

Home Atmosphere: [ ] Disturbed [ ] Congenial/Pleasant

Occupation of family members:

Interaction Patterns: Communication: ________ Leadership: ________
Cohesiveness: ________
Expressed Emotion & Attitude toward Illness:
7. Personal History
Birth History

Delivery: [ ] Full-term [ ] Pre-term | [ ] Hospital [ ] Home |

Birth Cry: [ ] Present [ ] Absent

Scholastic History: (Performance, regularity, peer relationships, current
status) ________________

Adolescent History: (Emotional/physical problems, pubertal
changes) ________________
Three Wish Test:
Animal Test:
- First Animal: How you want to be seen by the world (Desired selfimage):
- Second Animal: How you truly see yourself. (True self):
- Third Animal: How you actually show up to others. (Social
presentation):
8. Premorbid Personality Checklist

Social: [ ] Leader [ ] Follower [ ] Extrovert [ ] Introvert [ ] Shy [ ]
Sociable

Mood: [ ] Optimistic [ ] Pessimistic [ ] Stable [ ] Irritable [ ]
Worrying [ ] Calm

Character: [ ] Rigid [ ] Flexible [ ] Methodical [ ] Impulsive [ ]
Suspicious [ ] Sensitive

Standards: [ ] Perfectionist [ ] Self-critical [ ] Religious [ ]
Complacent [ ] High Aspiration
9. MSE - Observations and Speech

Appearance: [ ] Groomed [ ] Disheveled [ ] Inappropriate [ ] Bizarre

Eye Contact: [ ] Normal [ ] Intense [ ] Avoidant [ ] Others

Psychomotor: [ ] Increased [ ] Decreased [ ] Normal [ ]
Tics/Mannerisms

Speech:
o
Rate/Tempo: [ ] Fast [ ] Slow [ ] Normal | Reaction Time: [ ]
Increased [ ] Decreased
o
Volume: [ ] Loud [ ] Soft [ ] Normal | Tone: [ ] High [ ] Low
[ ] Normal
o
Coherence: [ ] Coherent [ ] Incoherent
10. MSE - Affect, Thought, and Perception

Affect: Subjective: _________________ Objective: [ ] Flat [ ] Blunted [ ]
Labile [ ] Congruent

Thought:
o
Stream/Form: [ ] Flight of ideas [ ] Blocking [ ]
Circumstantial [ ] Tangential
o
Possession: [ ] Obsessions [ ] Compulsions [ ] Thought
Alienation
o
Content: [ ] Delusions (Type: _________) [ ] Phobias [ ] Suicidal
Ideation [ ] Preoccupations
Thought Content

Delusions: Type: __________________________

Phobias: __________________________

Suicidal Ideation / Death Wishes: __________________________

Preoccupations: __________________________
Perception

Hallucinations: Modality: __________________________

Illusions: __________________________

Depersonalization / Derealization: __________________________
Advanced Psychotic Phenomena

Somatic Passivity: __________________________

Made Phenomena:
o
Made Affect: __________________________
o
Made Impulse: __________________________
o
Made Volition: __________________________
11. Cognitive Functions

Attention/Concentration: Digit Span (F: ____ B: ____) | Serial
Subtractions (50-7): ________

Orientation: [ ] Time [ ] Place [ ] Person [ ] Day [ ] Date [ ] Month
[ ] Year

Memory:
o
Immediate: (Digit span) | Remote: (Life events/DOB)
o
Recent: (24hr recall) | Address Test: Facts recalled: ____/5 |
Interference: ________

Intelligence/Abstraction:
o
General Information: Literate (PM/Capitals): ______ Illiterate
(Seasons/Crops): ______
o
Abstraction: (Similarities: Orange/Banana; Dog/Lion):
------------------------------------------------------------------------------------------------------------------12. Judgment and Insight
Judgment

Personal: __________________________ Social: __________________________ Test: ______________
____________
Insight Scale

[ ] I: Complete denial of illness.

[ ] II: Slight awareness of being sick but denying at the same time.

[ ] III: Awareness of being sick but blaming it on external factors.

[ ] IV: Awareness that illness is due to something unknown in the patient.

[ ] V: Intellectual insight.

[ ] VI: True emotional insight.
13. Diagnostic Formulation and Management
4P Model Formulation
Predisposing Factors
Precipitating Factors
(Genetic, family history, personality)
(Immediate stressors, triggers)
Perpetuating Factors
Protective Factors
(Maintaining factors, lack of support)
(Strengths, coping mechanisms)
Multi-modal Management Plan:

Pharmacotherapy:
_______________________________________________________________

Psychotherapy:
_______________________________________________________________

Family/Other:
_______________________________________________________________