Child Case History

Child Case History Form

1. Basic Information

Name

Age

Email address

Mobile Number

Basic complaint in detail

Since when?

How did it start?

Factors which increase or decrease the complaints:

Any other complaints?

Past history of all the other previous illnesses (major illnesses, any surgeries, skin eruptions, nappy rash, worms, milk intolerance)

Milestones (birth history, cry after birth, teething, walking, talking, vaccinations)

Any history of febrile convulsion, breath holding spasms?*

Any family history of illnesses (parents, siblings, grandparents etc)?*

2. Personal History:

How is his/her appetite?

What are his/her likings in food, taste, similarly dislikes, any craving for abnormal things (pica) like chalk, mud, pencils etc? *

Any thumb sucking, nail biting, grinding teeth, drooling of saliva or any such habits?*

How is his/her thirst for water?*

Enter bowel habits—any constipation, frequency of stools, diarrhea*

Is his/her Urination fine? Any bedwetting history? *

Perspiration--area, odor, any staining ?*

How is his/her sleep? What is the Position of sleeping? Any Dreams?*

Thermally - can he/she take heat more or cold more, bathing water, wants fan or air-conditioning, covering while sleeping required ?*

3. For Mothers:

How were your 9 months duration of the pregnancy, mentally as well as physically?

4. Mind -- Most important -- Please answer freely, frankly & Completely , please do not hold anything back be-open & forthright. Take help to answer if you find difficulty in answering a question or let us know if you do not understand the question.

How is his/her nature at home with family, in school, outside, with strangers etc? *

Describe your family structure-- Who all are there & How is his/her relation to each?*

Emotionally how is he/she? *

How is he/she with other kids? Does he/she share his/her stuff with them?

Is he/she active or lazy, anxious, fearful , stage fright, anxiety before exams-any symptoms ? *

Any anger bouts, effect of anger on him/her, response to being corrected or shouted at violent in any way? *

Any physical or mental hurt /trauma incurred, any separation history?*

What are the games he/she loves to play?* How does he/she react when he/she loses in the game?

How is he/she at keeping his/her things?*

Is he/she stubborn about anything?

Any fears like darkness, animals, etc? *

Any tics, involuntary movements of any part of the body?*

How is his/her Scholastic /academic performance, extracurricular activities?*

How do the teachers at school describe him/her?

How is the memory, grasping skills?

What are the Future career aspiration/ambitions? *