Clinical Intake
23-04-25
Date:______________
jannat
Name:_____________________________________________________ Sex: Male/ Female/ Child
Date of Birth:__________________________ Age:__________________Marital Status: S M D W Sep
Present Address:______________________________________________________________________
2nd year mbbs student
Phone:______________________ Education:____________________ Occupation: ________________
Father’s Name: _____________________Age:______________ Edu:____________Occu:___________
Mother’s Name: _____________________Age:______________ Edu:____________Occu:__________
Spouse’s Name: _____________________Age:______________ Edu:____________Occu:__________
Siblings: M_____F_____ B.O: __________ Family Structure: Nuclear / Joint
Children: 1:_______________2. _______________3._________________4._____________5._________
Head of Family:___________________________ Earning Members: _____________________________
Income Group:____________________________ Heritage:__________________________
Languages: English/ Urdu /Pushto / Sindhi / Balochi / Hindko/ Saraiki / Other:______________________
Appearance:___________________________________________________________________________
Referred By:___________________________________________________________________________
Assessment: I.Q Behavioral Personality Other:___________ Therapy
Referred To________________________________________________
Date of Referral_____________________________________________
Intake By:_________________________________________________
Previous Therapist___________________________________________
Date of Termination__________________________________________
Signatory of Authority
Clinical Intake
Presenting Complaint:___________________________________________________________________
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Additional Information__________________________________________________________________
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CASE HISTORY SHEET
Patient’s Name:___________________________________ Father’s Name:________________________
Therapist:_________________________________________ Date:_______________________________
Presenting Problems (nature of problems, precipitating events, patient’s feelings and thoughts about
the problem)
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History of problems (duration of present problem, changes in nature, intensity, and/or frequency of
problem over time, prodromal manifestations, other past problems of a psychological nature, no. of
attacks)
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Family History (migrations, births, marriages, serious illnesses, deaths, jobs of earning members,
relationship with family members)
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Family Psychopathology (nature, history and treatment of mental disorders on members of the patient’s
family)
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School History (marks/ divisions obtained, school changes, school problems, relationships with peers
and teachers, extra-curricular activities)
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History of Friendships (nature and extent of relationships, recreational activities, degree of religiosity,
sexual history- premarital, marital and extramarital sexual relationships)
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Prior Treatment (details of treatment sought for presenting problems and from whom, when and for
what duration treatment undergone; nature of treatment methods, names and dosages of drugs taken;
ECTs, faith healings and response to treatments including adverse reactions and/or side effects)
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Medical History (most recent physical exam: date and results, current medications, health conditions
since childhood including details of serious illness/ disabilities suffered and surgery undergone; eating
and sleeping if remarkable and any change of same, use of stimulants, alcohol and drugs)
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Somatoform (conversion, hypochrondriasis or other somatic complaints)
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Space for additional Information
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Tentative Diagnosis: _________________________________________________ Date:______________
Final Diagnosis:_____________________________________________________Date: ______________
Mental Status Sheet
Orientation (Date, Time, Place): Intact Broken
Sleep: Intact Broken Nightmares Sleepwalking Night terrors
Any Other: ____________________________________________________________________________
Attention (Concentration, Memory): Intact Broken Any other: ____________________
Perception: Intact Illusions Hallucinations (auditory, visual, tactile, somatic, olfactory)
Thought Patterns: Intact Suspiciousness Delusions Loosening of Association
Any Other:____________________________________________________________________________
Affect: Crying Spells Depressive Guilt feelings Suicidal Hostility
Excitement Grandiosity Blunted Effects Any Other:______________________
Speech: Mute Talkative Abusive Any Other:______________________________
Motor: Restless Assaultive Destructive Excited Retardation
Anxiety: Tension Nervousness Phobias Obsessions Compulsions
Any Other: ___________________________________________________________________________
Mannersism and Posturing: Unusual gestures Preservative movements Other:________
Psychosomatic: Obesity Headaches Painful menstrual Skin Disorder
Asthma Nausea Vomiting Vertigo Anorexia
Addictions: Narcotic smoking Chewing Tobacco Alcohol Gambling
Any Other: ____________________________________________________________________________
Interview Behavior: Open Secretive Anxious Relaxed Withdrawn
Timid Aggressive Complaint Cooperative Any Other:_________________
Strengths: Degree of Insight Motivation Intellect Level Mitigating
Psychosexual: Gender Identity Paraphilias Psychedelia dysfunction Intact
Personality Traits: Paranoid Schizoid Schizotypal Antisocial Borderline
Histrionic Narcissistic Avoidant Dependent Passive Aggression