Scribd
Upload
111 views4 pages

CASE HISTORY PROFORMA School

This document outlines a case history proforma for collecting a patient's socio-demographic information, chief complaints, medical history, and other relevant details. The proforma includes sections for reason for treatment, history of present problem, family history, personal history, pre-morbid personality, diagnostic impression, and recommendations. It provides a structured way to document key aspects of a patient's case history.

Uploaded by

Jasroop Mahal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
111 views4 pages

CASE HISTORY PROFORMA School

This document outlines a case history proforma for collecting a patient's socio-demographic information, chief complaints, medical history, and other relevant details. The proforma includes sections for reason for treatment, history of present problem, family history, personal history, pre-morbid personality, diagnostic impression, and recommendations. It provides a structured way to document key aspects of a patient's case history.

Uploaded by

Jasroop Mahal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 4

CASE HISTORY PROFORMA

 Socio-demographic information
Name Education
Date of birth Informant
Age Informant’s Reliability
Gender Source of Referral
Address
 Brief Statement about the patient’s place of living and circumstances :

 Reason for Treatment :

 Chief Complaints (even if nonsensical/non-plausible)


( ) Depressed mood ( ) Motivation
( ) Unable to enjoy activities ( ) Self-esteem
( ) Change in Sleep ( ) Peer relationships
( ) Loss of Interest ( ) Social skills
( ) Concentration/Forgetfulness ( ) Family concerns
( ) Change in Weight/Appetite ( ) Bullying - Victim
( ) Fatigue/Always tired ( ) Bullying - Bully
( ) Impulsive ( ) Educational Support
( ) Excessive energy ( ) Grief and Loss
( ) Increased Irritability ( ) Aggression
( ) Crying Spells ( ) Fighting
( ) Excessive Worrying ( ) Adjustment issues
( ) Nervous/Anxious/Panic ( ) Dramatic change in Behaviour
( ) Avoidance ( ) Self-Injury (ex: cutting)
( ) Day dreams/Fantasizes ( ) Stealing
( ) Sexual Acting out ( )Self-Image
( ) Personal Hygiene ( ) Lying
( ) Scared ( ) Defiant
( ) Hyperactive ( ) Attention-Deficit
( ) Homework Completion ( ) Other ____________________
( ) Organizational Skills

Case History Proforma Page 1


 Specifiers :
- Onset (Abrupt, Acute, Sub-Acute, Insidious) :
- Duration :
- Course (Continuous, Episodic, Progressive) :
- Precipitating Factor :

 History of Present Problem:

 Medical History
Chest Pain/ Pressure Asthma
Headache Dizziness/Fainting
Allergies Cancer
Eczema Difficulty Hearing
Seizures/Epilepsy Nose Bleeding
Vision

 Appetite :
- Number of meals a day :
- Balanced Diet : ( ) Yes ( ) No
- Allergies :
 Sleep :
- Number of hours each night :
( ) Difficulty falling asleep
( ) Difficulty staying asleep
( ) Frequent waking

Case History Proforma Page 2


 Family History (family tree, demographics of members, history of any mental or
physical illness, relationship between members, components of support system)

 Personal History (describe events of major significance throughout a person’s life,


highlight those that may be etiologically significant, descrive functioning over time)

- Developmental Milestones

- Childhood History (any difficulties encounteres. Ex: bedwetting)

- Adolescent History

- Educational History

- Vocational History

 Pre-morbid Personality (picture of an individual before the onset)

 Diagnostic Impression :

Case History Proforma Page 3


 Recommendations :

Case History Proforma Page 4

You might also like