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8/17/2019 GC_FORMAT
1/4Page | 1
P .G. Diploma in Guidance & CounsellingOrganized by
Ram akrishn a M ission Sikshan am and iraCollege of Teacher Education (CTE)
(A NCTE Recognized Residential Post-Graduate Autonomous College under theUniversity of Calcutta)
Belur Math, Howrah – 711 202, West Bengal
Regn. No. ______________________________ Date: ________________
Indoor Regn. No.________________________ Refd. By______________
CASE HISTORY RECORD SHEET
1. Identifying data:
i. Name ………...……………………………………………..
ii. Age ………...……………………………………………..
iii. Sex Male Female Transgender
iv. Education ………...…………………………………………
v. Occupation ………...…………………………………………
vi. Marital Status Single Married Widow Divorce
vii. Religion : Hindu Muslim Christian Others
viii. Present Address …...……………………………………………………………………………...
………………………………………………………………………………………………………….
ix. Permanent Address………..………………………………………………………………………
………………………………………………………………………………………………………….
x. Name of Father / Husband ……………………………………………………………………...
xi.
Socio-economic Status …………………………………………………………………….........
xii. Informant’s Name: ……………………………………………………………………………..
xiii. Relation with patient: …………………………………………………………………………
xiv. Reliability of source of information: Satisfactory / Unsatisfactory.
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2. Chief Complaint:
Duration of Current illness:
Mode of Onset:
Precipitating factors:
Course and Progression:
3. History of Present Illness:
4. Treatment history (Current Episode):
5. Past History:
Past Psychiatric Illness (Symptoms and Treatment):
Past Physical Illness (Symptoms and Treatment):
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6. Personal History:
Birth and Development:
Sexual and Menstrual History:
Marital Relation:
Habits and Addiction:
7. Family History:
8. Premorbid Personality:
9. Mental Status Examination:
General – Appearance and Behaviour:
Mood:
Affect:
Speech:
Volition:
Perceptual Disturbance:
Thought:
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Sensorium and Cognition:
(a) Alertness and consciousness: …………………………………………………………………...
(b) Orientation: …………………………………………………………………..............................
(c) Memory: …………………………………………………………………………………………
(d) Concentration: …………………………………………………………………………………..
(e) Language: ……………………………………………………………………………………….. (f) Abstract thinking: ………………………………………………………………………………
(g) Fund of information and intelligence: …………………………………………………………
(h) Impulse control: ………………………………………………………………………………...
(i) Judgment: ………………………………………………………………………………………..
(j) Insight: …………………………………………………………………………………………...
10. Physical Examination:
11. Provisional Diagnosis:
12. Prognosis:
13. Psycho dynamic formulation:
14. Treatment suggested/ Management Plan:
_____________________________
Signature of Case Taker