CASE HISTORY

Designed By:

Parnika Bansal

Psychologist & CBT Practitioner

A. BASIC INFORMATION:
1. Child’s secondary language:
2. Language spoken at home:
3. Does the child previously diagnosed (yes/No):
4. Previous diagnose:

B. PRIMARY CARE:

1. Parents Name:
2. relationship to child:
3. What kind of intervention or service are you seeking for child:
4. Who cares for the child:
5. How many hours per day is the child in a child care setting:
6. How many different people care for the child:

C. FAMILY HISTORY:

1. Child family structure (joint/ Nuclear/ nuclear in joint)

2. Does child have any sibling (Yes/No), if yes list all brother/sister or other children in the family
Sibling 1- relationship to child- Age- Sex- Living at home (Yes/No)
3. Father occupation
4. Mother occupation
5. What do you enjoy most about the child
6. What do you find most difficult raising the child

D. BIRTH HISTORY:

1. Was this child planned pregnancy?

2. Was the mother under doctor’s care?
3. Any history of miscarriage? List
4. Check any of the following complications that occurred in the pregnancy.
Difficulty in Conception , Abnormal Weight Gain, Toxemia Measles, German Measles, Excessive
Swelling, Emotional Problems, Placenta Praevia , Vaginal Bleeding , Flu Anemia, High Blood
Pressure , None
5. Maternal Injury?
Yes No
6. Hospitalization During Pregnancy?
Yes No
7. Medication used During Pregnancy?
Yes No
8. X-Rays During Pregnancy?
Yes No
9. Alcohol/Cigarettes/Other Drugs used During Pregnancy?
Yes No
10. At child's birth what was mother's age?
11. Fathers age?
12. Was the child born in hospital?
13. Pregnancy term? (Pre/Post/Full)
14. Birth weight (kg’s)
15. Child’s condition at birth
16. APGAR score
17. Birth cry (Immediate/Prolonged)
18. Delivery Mode
(Forceps Used, Breech Birth, Labor Induced , Cesarean, Cord around neck, Prolonged
Labor , Normal)
Other Delivery Complications

19. Incubator (Yes/No)

20. Breathing problems right after birth?
21. Supplemental oxygen? (Yes/No)
22. Was anesthesia used during delivery?
23. Length of stay in hospital (Days)

Mother (in days):

Child (in days):

E. DEVELOPMENTAL:

At what age did the child do the following?

1. Turn over (in months) *

By 7 Months 7 to 9 Months After 9 Months Skill not attained

2. Sit alone (in months) *

By 7 Months 7 to 9 Months After 9 Months Skill not attained

3. Stand alone (in months) *

By 12 Months 12 to 18 Months After 18 Months Skill not attained

4. Walk alone (in months) *

By 12 Months 12 to 18 Months After 18 Months Skill not attained

5. Speak first words (in months) *

By 12 Months 12 to 18 Months After 18 Months Skill not attained

6. Speak in sentences (in months) *

12 to 18 Months 18 to 24 Months After 36 Months Skill not attained

7. Was this child breast fed?

Yes No

8. When Weaned? (in months)

9. Was this child bottle fed?
Yes No

10. When Weaned? (in months)

When was this child toilet trained?

1. Is child toilet trained *

Yes No

Days (in months)

Nights (in months)

2. Did bet-wetting occur after toilet training?

Yes No

If yes, until what age? (in years)

3. Did bed-soiling occur after toilet training?

Yes No

If yes, until what age? (in years)

4. Were there any medical reason for bed-wetting and bed-soiling?

Yes No

Describe-

Has this child ever experienced any of the following problems?

5. Walking difficulty?
Yes No

6. Unclear speech?
Yes No

7. Feeding problem?
Yes No

8. Underweight problem?
Yes No

9. Overweight problem?
Yes No

10. Colic?
Yes No

11. Sleep problem?

Yes No
12. Eating problem?
Yes No

13. Difficulty learning to ride a bike?

Yes No

14. Difficulty learning to skip?

Yes No

15. Difficulty learning to throw or catch?

Yes No

16. Describe other difficulties

During this child's first 4 years, were any special problems noted in the following areas? If yes, please
describe

Eating?
Yes No

Motor skills?
Yes No

Sleeping too much?

Yes No

Temper tantrums?
Yes No

Sleeping too little?

Yes No

Failure to thrive?
Yes No

Separating from parents?

Yes No

Excessive crying?
Yes No

Describe other special problems

17. Which hand does the child use for

Writing or Drawing?
Left Right Both

Eating?
Left Right Both

Other?
Left Right Both

Has the child been forced to change writing hand?

Yes No
F. MEDICAL HISTORY:

1. Is your child’s immunizations status updated?

Yes No

2. Childhood Illness / Injuries-

Measles Rheumatic fever German Measles Diptheria Mumps Meningitis Chicken Pox
Encephalitis Tuberculosis Anemia Whooping Cough Fever above 104 Broken Bones Seizures

3. Head Injury(Describe)

4. Coma or Any Loss of Consciousness(Describe)

5. Sustained High Fever(Describe)

6. Please describe other serious illnesses or operations

Illness

Age (in years)

7. Has this child been on any medication for 6 months or more?

Yes No

If yes, when? What kind?

8. Please indicate whether this child has any of the following problems?
Cardiovascular (Shortness of breath, dizziness with physical excretion, Activity limitation due to Heart
Condition) Gastrointestinal (Excessive Vomiting, Frequent Diarrhoea, Constipation, Frequent Stomach
Pain) Genitourinary Musculoskeletal (Muscle Pain, Clumsy Walk, Poor
Posture) Skin Neurological Allergies (medicines, foods, other) Speech Hearing Vision Medical
care Habits (thumb sucking, bites nails)

9. Is child currently on medication? (other than multivitamin, iron and folic acid)
Yes No

If yes, describe

10. Has child ever had any therapy or early interventions?

Yes No

If yes, describe

11. Has child ever had neurological or psychiatric examination?

Yes No

If yes, describe

12. Other difficulties (Accident Prone, grinds teeth, has tics/twitches)

G. Physical Activities / Recreation / Hobbies

1. Sports
Regularly Intermittently None

Describe
2. Exercises
Regularly Intermittently None

Describe

3. Hobbies
Regularly Intermittently None

Describe

4. Other Interests
Regularly Intermittently None

Describe

H. BEHAVIOR/TEMPRAMENT

Please exhibit whether the child exhibits any of these following behaviors?

1. Is your child warm and affectionate?

Yes No

2. Does your child easily complies?

Yes No

3. Is easily overstimulated in play?

Yes No

4. seems overly energetic in play?

Yes No

5. Has a short attention span?

Yes No

6. seems impulsive?
Yes No

7. Lacks self-control?
Yes No

8. Overreacts when faced with a problem?

Yes No

9. Seems uncomfortable meeting new people?

Yes No

10. Can not calm down?

Yes No

11. Has fears?

Yes No

12. Does your child seems irritable?

Yes No
13. Does your child appears aloof?
Yes No

14. Requires a lot of parental attention or difficult to manage?

Yes No

I. FRIENDSHIP:

Please indicate how this child relates to other children

1. Has problems relating or playing with other children?

Yes No

If yes, describe

2. Fights frequently with playmates?

Yes No

3. Prefers playing with younger children?

Yes No

4. Has difficulty making friends?

Yes No

5. Prefers to play alone?

Yes No

6. Are there children in the neighborhood with whom this child could play?
Yes No

7. What role does this child take in peer group games? (for e.g. leader, follower, etc.)

8. Play Pattern?
Solitary Play Parallel Play Imitative Play Associative Play Cooperative Play

J. EDUCATIONAL HISTORY:

1. Which type of school does your child study? *

Pre School MainStream Special School Not going to school

2. Preschool and daycare

Any problems in daycare or kindergarten?

3. Primary/Secondary

4. Has changed schools for reason other than normal academic progression?
Yes No

5. Has retained or skipped a grade in school?

Yes No
6. Has difficulty in reading or math?
Yes No

7. Study Habits / Routines

Study Routine?
Regular Irregular

No of hours study in a day?

Less than 1 hour 1 to 2 hours more than 2 hours

Does the child go for tuition?

Yes No

Describe

A-B-C CHECKLIST

Date: Time: Location/Setting:

Antecedent (Before Behavior) Behavior Consequence (After Duration/Intensity
Behavior)
❏ Given direction/task ❏ Verbal redirection Duration:
❏ Difficult task/activity presented ❏ Physical redirection/prompt
❏ Preferred activity ❏ Teacher/Peer Ignored Start
interrupted/stopped ❏ Restated direction time:
❏ Preferred activity/item denied ❏ Verbal reprimand (told to stop)
❏ Ignored by peers ❏ Remove from activity/location End
❏ interaction w/ specific ❏ Given another task/activity
person/group ❏ Response blocked time:
❏ Parent/caregiver attention to ❏ Peer attention
others ❏ Other:
❏ Alone w/ activity
❏ Other:
Intensity:
1 2 3 4 5