EES s+ le CC Family History “ype of Family: Nuclear/JoinvOther ‘tatus of Family: IntacvBrokewDisjoined Sonsanguinity: Present/Absent (Specify relation, if present): lousehold composition: Include all members like grand parents, parents, siblings, relatives, others Occupation | Health | Attitude tNo ‘Name, | Relationship ‘Age/Sex | Education ily Genogram (at least three generations) mentioning details about first-Jegrec relatives- living idead (cause) ily History of Mental & Medical illness: Perso: tory jatal History (Mention time of pregnancy at which a Particular complain noticed): Janned/unplanned conception; wanted/nwanted child; attempted but failed abortion/Threaten: rtion/Bleeding during late pregnancy/RH incompatibility/Trauma il story of gestational diabetes‘bypertensionjjaundice movements: NormaVEXcessive/Sluggish/Not known6 Natal and Neoratal history (Birth to 28 days); Term: Full/Pre-term/Post-ternv/Postdated/Not known Delivery place: Home/Hospita/ Others (Specify) ; Delivery Type: Normal/Episiotomy/Forceps/Vacuum/Caesarian section/Not known Head injury during bith: YesNo/Not known Presentation: Normal/Abnormal/Not known, Prolapsed cord: Yes/No/Not known 1 Birth Weight: Nonmal (2.5 kg)High/Low/Not KnowwSpecify, if exact weight known Colour of | baby: Pink/Yellow/Blue/Pale/Not known Yes/No/Not known ‘ ‘Yes/No/Not known Postnatal history (upto 6 weeks): Immediate/Delayed/Not known (Specify if delay time known) Infections: YesNo/Not known Jaundice: YesNo/Not known Feeding problems: Yes/No/Not known Failure to thrive: Yes/No/Not known Injury: YesNoNot known Convulsions: YesNo/Not known (Specify if details known) Any others (Specify): on Feeding History: Breastfeeding: Exclusive/Mixed/Botle (if not breast fed, specify reason and comment on bott hygiene): ‘Weaning age: Developmental History: (Extract as much detail as possible) [| Gross Motor Expected | Achieved at | Fine motor/Cognitive | Expected | Achieved ® Neck holding J months _| Mature Pincer grasp | T year ‘Stands alone ¥ months Scribbles Tiyeans Walks alone 15 months Copies a circle T years Runs/walks up & down | 2 years | Identifies body parts years Rides a tricycle 3 years Cope ae S years Tanguage Expected | Achieved at | Soctal Expected | Achieved Babbling 6 months Social smile 2 months ylables ‘9 months Recognizes mother | 3 months] 2-3 word sentences 2 years Stranger anxiety ‘6 months Knows full name & 3 years ‘Separation anxiely Tyear eet morypoem ‘years Pretend/Parallel Play [273% yx3 ee aes years ‘AssociativelCo- 374 years ‘Asks meaning of wor oe Self Help [Feeds independently | 1@months Bladder control <3 years rashes teeth years Dresses selt Tyeans Bowel Control <4 years anScholastic History; > Type of School: hoo: Norma SchooVSpecial School/At home/Religious School/Other * Ageofentry: > Schooling detai : chooling details (mention changes in schools, durations with reasons) ® Scholastic performance: Good/Average/Poor/Not known (mention failures if any) > Disciplinary actions: Yes/No/Not known > Attendance: Regular/Irregular/Discontinued/Not known ‘ > Reasons for irregularity or discontinuity: School refusal/wanders/fearful/financial problems/poot Progress/Behavioural problems/Request of school authorities/others (specify) > Peer group adjustment: Good/Adequate/Poor/Not known > Relation with authorities: Good/Adequate/Poor/Not known > Any other information: Play History: ' > Play Behaviour: Enjoys play/Not interested in play/Observes others while playing/Other t » Reasons for poor play behaviour: No company/Siblings or peer group not interested in playing with the child/quarrelsome/overprotected by parents or care-takers/poor play facilitics/other (specify) > Play preferences: Plays alone; with older/younger/pecr group/animals; no preferences/others: > Knowledge of games governed by rules: Yes/No/Not known > Behaviour while playing in-group situations: Normal/Poor/Not known > Leisure time activities: <> Special likes and dis!Sexual and marital history: > Attained menarche: Yes/No/Not applicable (Specify age at menarche if, applicable) Scanned by Cam: | 9 Details of menstruation: (Duration of usual cycle, regular/irregular, associated with physical or psychological symptoms or not, information and attitude towards mensuration, Last menstrual Period, duration and reasons of amenorthea, if any) Gained sexual knowledge: (From whom and wien) ‘Sexual activities: (current and past, include eny details of childhood sexual abuse if available) Marital Status: If married, then mention age at marriage, parental consent, child's consent, and relevant details about spouse, role allocation & sbaring of responsibilities between partners, sexual relations & contraception, genogram for family of procreation scupational History: Duration, reasons for leaving, relation with work mates and superiors and ter relevant details rensic history:& aperament: Information should be obtained regarding child's temperament before the onset of toms if he has illness or when the child has been his most usual self if he has no illness tivity level: How active is your child? Do you find him so active that he runs rather than walks or “he inactive that he hardly moves? While eating does he eat staying still or does he keep moving 1 (Completely still very little movemenvalways on the move) tention span & Persistence: If you try to interrupt your child’s activity, does he try to go back to it ves he forget it? If your child finds a game or piece of work difficult, does he tum into another ity or keep on trying until he leams it? (No persistence’ continues till he achieves what he sets out proach withdrawal: What is your child’s first reaction when he meets children of his age for the ime? If he is given a new food or placed in a new situation, what is his first reaction? (Feels ned, cries, withdraws physically/ goes spontaneously) y)_-Pebily: If your child has been shy with some children, how long does it take him to mix and endly? Does he settle back in schoo! routine quickly after a long holiday? (No adaptability initial vn of withdrawal is only momentary) Scanned by CamScanner 10 9) Distractibitity: If he is annoyed ot isin bad mood, can he be easily joked out of ito it very difficult ‘0 do so? Do you find that when he is engrossed in an interesting task, you have (0 call out several times before he hears or responds? (Low distraction/Highly distractable) ©) Intensity of reaction: Wha be is not given something that he wants, how does he bebave? What is ! his reaction if he is given some food that he li i ing wit likes very much? (hardly any reaetion/ roaring with laughter) fond ' 7) Threshold of responsiveness: Does he sccm to bother by minor ‘or sounds or does he ignore 1 those? Does the child have to be seriously injured before he comments, ties about culs/bruises? (easily bothered — low threshold not bothered — high threshold) i ¥ ris 2 Quality of mood: \s your child generally happy, satisfied or generally unhappy or discontented? ¢ When playing with other children, docs he argue/fight with them? (Always crying, angry, irritable/always laughing, giggling, happy) y laine ; vl Rhythmicity: Does your child feel hungry/go to sleep/ have bowel movement at the approximately “* ‘same time every day? (Always variable/predictable) li ‘entify auributes that appear extreme in their manifestations, und those, which seem clearly related to ts current pattern of deviant behavior to give the final impression. Impression: eeae ee Behavioural Observation i wh General Appearance and behaviour: (physical appearance, appropriate 10 age, body built and g dress, physical handicaps if any’ Relationship capacity and sociability: (response to separation from parents, reaction to inte Situation and relation with interviewer) Spontaneous motility and activity level: (retarded, hyperkinetic, quiet); Motor behavior (Stereotyp, tics, self injurious behavior) 9 Speech: (flow, form, level of development of speech, inappropriate use of speech) Affective behaviour: (any evidence of anxiety, fear, depression, shyness, including child’s atitw towards examiner) E Antention span and distractibility: (assign some simple task as drawing, writing; also from ably engage in conversation) Intellectual capacity: (ask the child to show body parts; identify common objects by name or use name primary colors; draw figure appropriate to age) Stated imerests and content of thought: (child's evaluation of problems; any disturbance of thought) + ' Motivational insight (child's knowledge of reasons for problems, desire for help, sense of owm capact for change) “Play Behaviour (Ieave the child with toys in a room with observer; parent can be allowed to be with child initially)