Date: / /Therapist:1

Case File

File No.:------

Date: / /Therapist:1------

Psychiatrist:2------

Patient’s Name: ------

Date of Birth: Day Month Year Sex: M F

Social Status: S M D W Child

Civil Status: R C

I.D No. : ------

Address : ------

Telephone No.: ------

Occupation: ------Education: ------

Care taker Occupation: ------

House:Own Rent Homeless

Living: With extended family With nuclear family Alone

Diagnosis: ------

------

Referred by: ------Outcome: ------

Treating Team:Doctor : ------

Psychologist : ------

Social worker: ------

Nurse : ------

Team Leader:------Signature:------

Present Complaint:-

------

Present History:-

------

Have you been

atric )

Condition / Age at onset / Duration / Treatment

Personal History

Pregnancy: ------Delivery: ------Milestones: ------

Marriage: ------Age: ------No of marriage: ------Marital Relations: ------

Adolescence:------

Sexual Problems:------

Hobbies and habits:------

Significant life events:-

Event / Age / Effect

Family Tree:

Children

Family Relations, Conflicts, Problems:

------

Socio-economic Sit:

------

Family Psychiatric & Medical History:-

Relation to patient / Condition / Treatment / Current Condition

Physical Examination:-

B.P. ------Pulse ------

Chest ------Heart ------

Abdomen ------

Neurological exam ------

------

Mental State Examination

1- Appearance and behavior:

- Self Care:Good Bad

- Eye Contact:Good Avoidant None

- Social:Friendly Suspicious Hostile Aloof Angry

- Motor Activity:Normal Hyperactive Agitated Restless

Retarted Hypoactive Catatonia Tics Mannerism Posturing

2- Speech:

- Amount:Normal Increased Decreased

- Speed:Normal Fast Slow

3- Thought:

- Association:Normal Loose Clang Flight Neologism Blocking

- Abstract Thinking:good Impaired

- Content:Delusion Bizarre Systematized Nihilistic

Paranoid ( Type:------

- Phobia:Agoraphobia

Social phobia

Simple ( Type ------)

- Obsession Content: ------

- Compulsion Content: ------

4- Affect:Appropriate Inappropriate Flat Blunt Restricted Labile

5- Mood: Normal Apathetic Indifferent Elated Depressed Euphoric Anxious

6- Cognition:

- Disorientation:Time Place Person

- Concentration:Good Impaired

- Attention:Good Distractible Hypervigilance

- Memory:Immediate Good Impaired

Short Good Impaired Long Good Impaired

Amnesia:Specify:------

7- Perception:Normal

- Illusion Sensory Organ ------Content ------

- Hallucinations Sensory Organ ------Content ------

- Depersonalization De realization

8- Insight: Full PartialLost

& Judgement:Good Impaired

Summary of the case

------

Multiaxial Evaluation

AXIS I: Clinical Disorders

Other conditions that may be a focus of clinical attention

------

AXIS II: Personality DisordersMental Retardation

Personality TraitDefense Mechanism

------

AXIS III: General Medical Conditions

------

AXIS IV: Psychosocial and Environmental Problems

Problems with primary support group ------

Problems related to the social environment ------

Educational problems ------

Occupational problems ------

Housing problems ------

Economic problems ------

Problems with access to health care services ------

Problems related to interaction with the legal system/crime ------

Other psychosocial and environmental problems ------

AXIS V: Global Assessment of functioning scaleScore: ------Time Frame: ------

Management Plan:

1- Psychotherapy:

Type:Sessions

------

2- Psychological Testing:

Test PsychologistResult

------

3- Medications:

Name / Form / Dose / Frequency / Duration

4- Social Interventions:Visit: Yes Visitor ------Place: ------

Aim: ------

------

5- Consultation and Investigations needed:

------

FOLLOW UP

Date: ------Session -Psychotherapy

------

Therapist ------Signature: ------

FOLLOW UP

Date: ------Session -Psychotherapy

------

Therapist ------Signature: ------

DRUG SHEET

Name: ------File Number: ------

Date / Treatment / Signature
Name / Form / Dose / Frequency / Duration