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CASE HISTORY
Centre:
Registration No.: Date:
Name: Gender:
D.O.B: Age:
Address:
Educational Qualifications:
Occupation: Income:
Marital Status: Children:
Patient stays with parents / Spouse:
Have any siblings if so, how many:
What is the position of the patient in the family?
Anyone in the family is suffering /has suffered from any mental disorder:
Anyone in the family is suffering / has suffered from any physical disorder:
Characteristics of symptoms:
Presenting of Symptoms:
Date of onset of illness (the first attack):
Duration of illness:
Intensity of illness (on a scale of 10):
