Case History Format to fill Client Details

 Case History Method:

It is necessary to take case history of a subject so as to understand his/ her back ground. Case history covers personal information like name, age, gender, religion, education, income, socio economic status etc. It further covers information about family, job if any, medical complaints, medical or any other treatment or help sought by the subject.

A particular format may be followed by Psychologists in order to take case history of a subject.

A sample of Case History Format is given as follows:

• Personal details: These are mainly for the identification of the subject and to understand his/ her basic details. This will be followed by certain other details about the subject. They may be

Name:

Address:

Contact No.:

Gender: Male/ Female

Age:

Marital status:

Occupation:

Referred by:

Main/ Present/ Chief Complaint:

• Personal History/Development: This can cover various aspects like early development, childhood, school, adolescence, occupation, menstrual history, sexual history, marital history, details about children, social network, habits, leisure and forensic history.

• History of Present Illness: These are details of problems experienced by the subject. This covers common psychiatric symptoms , comment on the impact of the illness on the subjects’ life, work, social relations and self-care. Details of previous treatment are also to be noted down with details about current problem and psychiatric issues. Further, details of previous episodes of illness, previous psychiatric admissions/treatment, suicide attempts/drug and alcohol abuse, interval functioning (what is the subject like between episodes/when “well’).

• Medical History: The details of medical treatment that the subject has undergone or is undergoing has to be noted down.

• Family History: Parents and siblings, nature of the relationships between family members.

Any family tensions and stresses and family models of coping. Family history of psychiatric illness (incl. drug/alcohol abuse, suicide attempts).

• Social History: The social interactions of the subject, including behaviour at work or in school or during social gatherings is to be noted down.