CASE TAKING PROFORMA Serial No: --
Date: __--__--____
A) Patient’s Biodata: Name: ………………………………… Age: ……….. Sex: M/F Martial Status: Single/Married/Divorced/Widowed Single/Married/Divorced/Widowed Residence: Urban/Rural Occupation : …………… Socioeconomic Status: High/Middle/Low B) Presenting Complaints : C) History of the present Illness:
(Detailed history of present illness with respect to cause and circumstances, duration, mode of onset, location with extension, sensations, modalities and concomitants, if any) D) History of the previous Illnesses:
Past Medical H/o patient as per the check list given at the end. E) Family History:
In his own, paternal and maternal families as per the check list at the end. F) Personal Details: APPEARANCE:
Lean/Obese/Emaciated/Average/Thin/Short/Tall/Stooped/Undernourished WEIGHT: (Increasing/Decreasing/Stationary) APPETITE/TASTE/THIRST: AVERSIONS, DESIRES & EFFECTS OF FOOD: STOOL AND URINE: PERSPIRATION: MENSTRUAL FUNCTION: Menarche: Late/Early
L. M. P.
Menses: Cycle and Duration with concomitants: Menopause and associated complaints: Leucorrhoea: PREGNANCY AND OBSTETRIC HISTORY: G P A: Mode of deliveries: Mental State during and after Pregnancy Illness and Medication during Pregnancy: H/o oral contraceptives used SEXUAL FUNCTION: Desire/Aversion/Performance and associated complaints. PAEDIATRIC HISTORY: Birth: Normal /Abnormal Birth Wt.: Mother's health: Neo-natal problems: Milestones: Problems: Physical Development / Mental Development Speech: Retarded/Lisping/Stammer/Slow/Rapid Feeding: Breast/Top/Bottle/Solids Observation: Activity: Hyper/Dull/Restless/Destructive/Quiet. Emotional: Anger/Fears/Attachments/Shyness/Change/Responsibility Intellectual: Performance at School and in Extra-curricular activities Hobbies Obedience Socialization Aggressive(Beats, Bites)/BreathBehavioural Problems: holding/Clinging/Contrary/Cruel/Criminal/Dirty/Fastidious/Headbanging/Obs essive/Homesick/Hurry/Stealing/Nailbiting/Obstinate/Rocking/Tantrums/ Tics/ Thumb sucking/ Truant/Weepy SLEEP & DREAMS: Type of sleep: Light/Catnaps/Deep/Un-refreshing/Poor/Siesta Disturbed Due To:
Anger/Anxiety/Work stress/ Dreams/Fears/Lovesick/Thoughts Position during sleep Any change in sleeping pattern Concomitants: Enuresis/Gestures/Grinding/Moaning/Nightmare/Perspiration/Salivation/ Snoring/Starting/Talking/Walking Dreams and their nature : REACTIONS: [Physical factors: (Effects, Ailments from, Agg.
And Amel.)] Air: Cold/Open/Fan/Drafts/A.C./Closed room Weather: Clear/Dry/Foggy/Storm/Cloudy/Humid/Cold/Damp/warm/Seashore Seasons: Summer/Spring/Monsoon/Winter/Autumn Wet, getting: General/Local Covers: Covering/Uncovering, Bath
Motion
Time
Position/Posture
Coition
Meditation
Music/Noise/T.V. Light/Lightening/Moonlight Odors/Pain/Color/Dark/Touch/Pressure/Rubbing Sun exposure/Temperature/Thunderstorms/Moon phases Exertion: Physical / Mental Thermal state: Hot/Chilly/Ambithermal Anything else……. G) Emotional State:
LOVE/ ANGER/ SADNESS/ FEAR/ ANXIETY/HATE/ GUILT/ ENVY / JEALOUSY / SUSPICION AND OTHERS H) Intellectual State:
PERCEPTION/THINKING/MEMORY/DECISION/CONFIDENCE/CONSCIOU SNESS/WORK/PERFORMANCE AND OTHERS I) Life situations and circumstances: Self: Major areas of concern and worries: Past:/Present
Major fears Habits and Hobbies Family Patient’s position in family Spouse Dependents Relationship with wife and children Relationship with parents and siblings Marital Relationship Environment at home Work Environment at work Relationship with Juniors/Seniors/colleagues Job satisfaction Society Relationship with friends and relatives J) Body Language:
Gait: Gestures: Postures: Facial expressions: Eye Contact Voice and speech: K) Physical Examination General : Temp. Jaundice Mouth
B.P. Pulse Oedema Anemia
Cyanosis Ear Nose Throat
Tongue Lymph nodes Sinuses
Skin: Complexion & Texture, Discoloration, Eruptions, Growths Nails: Brittle, Clubbing, Colour, Deformed, Ingrown, Infection Hair: Growth, Baldness, Colour, Dandruff, Dry, Loss, Tangled L) SYSTEMIC EXAMINATION:
RESPIRATORY CVS
PER ABDOMEN CNS
MUSCULO-SKELETAL Comments if any: Questionnaire used to elicit the symptoms of the patients: Patients and the attendants were given ample time to explain about the problem, without interrupting them in haste, yet as and where needed the following type of questions were used; 1. What are the factors that make you worse? 2. What are the factors which make you comfortable? 3. What are the concerns in your life those are bothering you much? 4. In what type of environment you like to be? 5. How will you describe yourself i.e. your nature, behavior, temperament, likings, disliking etc? 6. What fears do you have? 7. How do you react to different situations? 8. What gives you the pleasure most? 9. What makes you angry or anxious? 10. Apart from your business/profession what other activities you like. 11. Which was the worst event of your life? 12. Which were the happiest moments of your life?
Checklist for Past and Family History: Anaemia
Heart diseases
Hypo/Hyper - tension
Asthma
Resp. diseases
Syphilis / Gonorrhoea
Diabetes
Rheumatism /O.A. R.A. / S.L.E
Cancer
Leprosy
Skin Diseases
T.B./Pleurisy
Musculo-skeletal
Paralysis / Polio/Stroke
Injuries / #
Jaundice
Poisoning / Pollution
Bleeding Tendency
Malaria / Typhoid Epilepsy / Fits
Chicken-pox/ Measles
Mumps / Rickets Stones / Renal diseases
Cholera /G.E. /Ulc. colitis
Mental retardation/Suppressions
Diarrhoea/Dysentery Neurosis / Psychosis Vaccination Exposure : x-ray / radiation
Otorrhoea / Otitis
Warts / Growths
Worms
Whooping cough
Anything else
Checklist of some Probable Causes Emotionally disturbing experiences in childhood. Prolonged insecurity. Feeling of unloved / unwanted during childhood. Preference of brother / sister. Death of family member / friend. Disappointment in a love affair. Career disappointment. Unfavourable work situation. Domestic quarrels between parents / spouse / siblings. Separation from parents / spouse. Loss of social position. Disappointment in close relationships Work stresses. Retirement from work. Strict upbringing during childhood. Major personal injury. Monetary losses. Unemployment. Change in Job / Residence. Any other.
Checklist of some Important Observations that can indicate Anxiety Disorders Hyperactivity of Hands. Fine Tremor of hands. Profuse and cold perspiration Palms and Forehead. Increased Pulse rate. Rapid and short breathing. Facial expression. Biting nails. Tenseness of facial muscles. Hands held in a fist. Crossed Arms. Shoulders Bent forward. Crossed legs. Shoulders bent forward. Head thrust forward. Sitting bent forward. Clenched Jaw. Restlessness of limbs. Avoids Eye Contact. Chafed and reddened Hands. Patchy hair loss.
