HISTORY SHEET FORM

File No: _________________________

Dated: __________________________
Name________________________________________________Sex________
Date of Birth________________Age__________Marital Status:S M D W Sep
Present Address________________________________________________________
Cell No________________Education__________________Occupation____________
Fathers Name_____________Age___________Edu________Occ________________
Mothers Name____________Age___________Edu________Occ_________________
Spouses Name___________Age___________Edu_________Occ________________
Siblings: M______F________B.O____________Children (sons & daughters) _______
Family Structure________________ __________Head of Family_________________
Income Group______________________Heritage_____________________________
Language________________________________ Informants Name______________
Referred By____________________________________________________________
Intake by ______________________________________________

---------------------------------------------------------------------------------------------------PRESENTING COMPLAINTS (nature of problems, precipitating event, clients thoughts

and feelings about problems)
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HISTORY OF PROBLEMS (Manifestation and Duration of Problems Nature of Past and

Present Problems, Intensity/Frequency of Problems)
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PRENATAL AND BIRTH HISTORY

Birth_________________________________________________________________
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MOTOR MILESTONES
Crawling_______________________________________________________________
Sitting_________________________________________________________________
Holding/catching________________________________________________________
Standing/walking________________________________________________________
Running/jumping________________________________________________________
Others________________________________________________________________
SPEECH MILESTONES
Speech________________________________________________________________
Words________________________________________________________________
Speaking______________________________________________________________
Language______________________________________________________________
Sentence______________________________________________________________
Story_________________________________________________________________
Others________________________________________________________________

MEDICAL HISTORY (detail of illness, physical examination, surgery & health condition)
High Grade fever___________ Epilepsy________________ Brain damage_________
Downs syndrome_________________________________ cerebral palsy___________
Brain injury_______________ Brain Hemorrhage________ Enlarged Head__________
Convulsions_______________Allergies________________Asthma________________
Tonsillitis____________ Ear drainage______________
Other_____________________
Detail of above problem___________________________________________________
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PRIOR TREATMENT
Diagnosis/Symptoms_____________________________________________________
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Who and where Diagnosed? _____________________________________________
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Medication/Method of treatment____________________________________________
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Duration of treatment____________________________________________________
Recovery/relapse/Side effects______________________________________________
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Others________________________________________________________________
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FAMILY HISTORY (migration, birth, marriage, deaths, earning, members, behavior and
relationship with family members)
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SCHOOL HISTORY
Marks/divisions obtained
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Strength & weakness in subjects
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School changes/problems/relationships____________________________________
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Extra-curricular activities__________________________________________________
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Others________________________________________________________________
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SOCIAL/ FRIENDSHIP HISTORY (Relationship with teachers, peers class-mates,
personal, communication, daily living skills, play & leisure activities)
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CHILDHOOD/DEVELOPMENTAL DISORDERS
Intellectual functioning
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Academic achievements
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Social adaptive behavior functioning
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Developmental problems & phonological problems
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ADHD, Conducts, Autism, Oppositional & Tics
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Others________________________________________________________________
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COGNITIVE DISABILITY
ORIENTATION (person, place, time, day, months & years)
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MEMORY (attention & concentration)
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PERCEPTION (illusions, hallucinations-auditory, visual, tactile, somatic, olfactory)
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FAMILY PSYCHOPATHOLOGY (nature, history, treatment of mental disorders in

members of patients family)
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BEHAVIORAL OBSERVATION (open, secretive, anxious, withdrawn, cooperative, and
aggressive & abusive, restless, assaulting, destructive, excited & muscle retardation)
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STRENGTHS
Degree of insight________________________________________________________
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Motivation level_________________________________________________________
Intellectual level_________________________________________________________
Others talents/circumstances______________________________________________
Specific underline dynamics_______________________________________________
TENTATIVE DIAGNOSIS
XI Disorder_____________________________________________________________
XII Disorder____________________________________________________________
RECMMENDATIONS (List of tests)_________________________________________
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Duration of
treatment____________________________________________________
Psychotherapy sessions__________________________________________________
Follow up sessions______________________________________________________
Reassessment__________________________________________________________

Date____________________
(Interviewer) _________________________________________________________
(Signature)