DEPARTMENT OF CLINICAL PSYCHOLOGY

SRM UNIVERSITY

Proforma for detailed case work-up of child and adolescent clients

1. Socio-Demographic Details

CP: No:
Name: Age: DOB Sex:
Date of evaluation:
Place of residence: Educational Status
Address

Source of referral
Information gathered from

a b c

Relaibility and Adequacy of information:

II. Presenting Complaints

Chronological list of complaints with duration:
Record the complaints in a chronological order. Do not write a long list of
complaints, but present the salient disturbances in the different areas of functioning. The
duration of the signs and symptoms also have to be elicited and recorded.

III . History of Present Illness

Describe in accordance with the following scheme

1. Onset Note if the onset of the symptoms is

i. acute (i.e. developing within few hours, generally < 48 hours),
ii. sub-acute (few days to few weeks, generally 2 weeks) or
iii. gradual (few weeks to few months).
2. Precipitating factors stressors, any other causative factors, initial symptoms.
Enquire about any precipitating events. These could be
physical (e.g. A febrile illness, viral infections )
psychological in nature (e.g. Death / loss).

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 DEPARTMENT OF CLINICAL PSYCHOLOGY
SRM UNIVERSITY

3. Descriptive account of chronological evaluation of symptoms (cross-sectional

describe at key points if necessary)
The course of an illness can be
i) episodic (discrete symptomatic periods with intervening periods of normalcy),
ii) continuous ( ongoing symptoms with no intervening periods of normalcy) or
iii) fluctuating (periodic exacerbations of a continuous illness)
At times a different pattern of symptoms may evolve in a continuous illness

4. An account of current problems, at the time of presentation.

5. Treatment history till date

6. Negative history

7. Family perception and responses to the problem

8.
Graphic charting of illness over lifetime if needed.

III. Family History

Describe under the following sub- parental relationships, between sibs,

headings
1. Genogram (Family Tree)
2. Family history of psychiatric and
other medical illness
3. Living arrangements, past and
present, including family type
4. Descriptive account of parents,
followed by a brief account of other
family members including sibs if
relevant
5. Home and neighborhood
6. Family life and relationship include
daily life pattern, cohesiveness,
emotional atmosphere, interact ional
patterns, communication styles,
child’s integration or participation in
family rituals.
7. Child rearing practices
8. Any other relevant information about
the family support systems of the
family, family dynamics (mention
Dysfunction \ pathological patterns
such as coalitions, schism,
scapegoating etc. if they are evident
at this stage) and family level stress

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 DEPARTMENT OF CLINICAL PSYCHOLOGY
SRM UNIVERSITY

IV. Personal History

Describe under the following sub-headings

1. Significant Prenatal History ii)Language

Babbling
Mother’s health during pregnancy First word
Significant illness :e.g Rubella(German 2 – 3 word sentences
measles), any viral infections Present vocabulary and language.
Hypertension/ Hypotension Impression: Delayed / Within Normal
Medications used during pregnancy Limits

iii)Self Help Skills

2. Significant perinatal factors Eating: Independent/Semi Dependent/
Full Term / Pre Term Fully Dependant
History of Hypoxia, Post Partum Depression Bathing : Independent/Semi
Type of delivery:Normal/Caesarian,Home Dependent/ Fully Dependant
Birth Weight Grooming : Independent/Semi
Birth Cry Dependent/ Fully Dependant
Dressing : Independent/Semi
Dependent/ Fully Dependant
Toilet Training

3.Postnatal development
i)Motor Mile Stones 5.Schooling history
6. Habits interests and talents
Neck Control 7. Sexual history
Turning Over
Crawling
Sitting with support
Sitting without support
Standing with support
Standing without support
Walking with support
Walking without support
Impression: Delayed / Within Normal Limits

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 DEPARTMENT OF CLINICAL PSYCHOLOGY
SRM UNIVERSITY
V. GENERAL TEMPERAMENT AND PERSONALITY ATTRIBUTES

i) Activity level. Whether the child is generally active and energetic, calm and quiet, or dull
and withdrawn
ii) Rhythmicity (Regularity) of biological functions: Whether the sleep, feeding and
excretory patterns are regular
iii) Approach or Avoidance: Whether the child approaches or avoids when presented with a
novel situation or object
iv) Adaptability: How easily can the child accommodate changes in environment and routine
v) Threshold of responsiveness: The sensitivity of the child to changes or the amount of
change required to elicit a response from the child.
vi) Intensity of Reaction. The degree or extent of response of the child to stimulation
received.
vii) Quality of Mood. The general mood state as being pleasant, irritable, crying easily etc.
viii) Distractibility
ix) Attention Span and Persistence
x) Qualitative Analysis: Easy /Difficult / Slow to Warm temperament.

VI. Past History

(Significant physical or psychiatric problems prior to the onset of present illness). a)Somatic
Complaints:
(eg. Headaches, Stomachaches, Sensory deficits, Seizures, Dissociation)

b). Behavior problems (e.g. thumb sucking, nail biting, stuttering, nightmares, night terrors,

bedwetting, lying ,truancy, stealing ,lying, destructiveness, fire setting etc)

VII. Physical Status:

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 DEPARTMENT OF CLINICAL PSYCHOLOGY
SRM UNIVERSITY
i) Nutritional State

ii) Age appropriate Height / Weight

iii) Signs of Dysmorphism

iv) Physical injuries, bruises, burns

v) Activity Level (Restless feeling, tics or mannerisms, lethargy, drowsiness)

VIII. Social Relationships:

i) Early mother child relationship (Quality)

(Check for post partum depression, separation anxiety)
ii) Response to strangers
iii) Peer relationship –
a) Special friends,
b) Groups
c) Solitary Play
d) Co-operative play
e) Imaginative Play

iv) Quality of peer relationships

a) Cordial
b) Confiding
c) Distant

v) Parenting
i) Permissive, Restrictive, Accommodating
ii) Communication
iii) Criticism, hostility, rejection
iv) Encouraging, Supportive, nourishing
Any other relevant information

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 DEPARTMENT OF CLINICAL PSYCHOLOGY
SRM UNIVERSITY
IX. Psychiatric Examination
Describe MSE under the following

1. Initial Observation 8. Mood and affect

2. Attention and Concentration 9. Thought processes
3. Activity Level 10. Perception
4. Motor behavior 11. Child’s version of the problem
5. Speech and language Ability 12. 3 wish test
6. General Intelligence 13. Tasks given to the child and comments
thereon
7. Other cognitive functions 14. Any other observation or comments such as
play room observation.

X. Physical Examination

Always record deficits in vision, hearing if any, physical handicaps/deformities, pubertal status
and birthmark (Mention any important findings here)

X. Summary

XI. Multi-Axial Diagnosis

Before Discussion After Discussion

Axis 1

Axis 2

Axis 3

Axis 4

Axis 5

XII. Detailed notes of discussion with supervisor

XIII. Plan of action management steps

List sequentially, numbering 1, 2, etc.

Case worked up by: Trainee Status: Supervisor: