CASE HISTORY FORM

DATE SEEN:
COMMENTS:

SECTION ONE: IDENTIFICATION INFORMATION

Case No._____________ Client’s Name: ______________________

Address: ____________________________________________________________
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Referred by: __________________ Occupation: _________________________
Age: _______________ Marital Status: _______________________
Client’s Position in the family: ___ birth order among __________ siblings
Ethnical Affiliation: _______________ Cell #: _________________________

Presenting Complain:
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 SECTION TWO: CLIENT’S BACKGROUND

Home Atmosphere in Childhood:

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Home Atmosphere Now:

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SECTION THREE: EMOTIONAL RELATION

Between Client and Spouse: ___________________________________________

Between Client’s Parents:
With mother: _______________________________________________________
With father: ________________________________________________________
With Client’s Children: _______________________________________________

SECTION FOUR: THE CLIENT’S CHILDHOOD

Birthdate: ________________ Birthplace (city, state): _____________________

Pregnancy (describe any unusual symptoms/problems):
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Earliest Childhood Memory:

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Childhood Habit (bed-wetting, thumb-sucking, nail biting, etc.)
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Notable neurotic trends in childhood (tantrums, sleep walking, etc.)
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Sources of irritations:
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Did client experience loneliness as a child?
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What fears were present in childhood?
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Shocks of any kind receive in childhood:
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 SECTION FIVE: THE CLIENT’S SCHOOL LIFE
Grade Completed: ______ Retentions: _____ Grades: _______
School______________________ College: ___________________________
University: _______________________________________________________
Attitude towards school:
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Attitude towards teachers:
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SECTION SIX: THE CLIENT’S BACKGROUND

What occupation is chosen? _________________ Why? ____________________

Was client forced into present occupation?
If so, under what circumstances:
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Has there been a change of occupation? If so, why?
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What does client want to do?
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SECTION SEVEN: CLIENT’S PHYSICAL CONDITION

Height: ____________ Weight: _____________ Appearance: ________________

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 Good Fair Poor
General Health _______ _______ _______
Vision _______ _______ _______
Hearing _______ _______ _______
Any abnormality:
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Effects of earlier operation:
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Heart conditions: ________ Lungs: _____________ Reflexes: ______________
Bowel and Urinary Infections:
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Alcohol: __________ Drugs: ____________ Tobacco: ________________

Special Notes:

SECTION EIGHT: CLIENT’S SOCIAL LIFE

☐Good mixer ☐Aloof ☐Nervous At home with people: _______________

What type? (Social Style):
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Attitude towards Social functions:
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 SECTION TEN: CLIENT’S SPRITUAL LIFE
What place did religion occupy in your home as a child?
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What place does it occupy in your home now?
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Who taught you to pray as a child?
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What were your ideas of God as a child?
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Religion/Denomination: _______________ Activities: _________________
Special Notes:

SECTION TEN: CLIENT’S PHYSICAL CONSITION

How do you sleep? ________ How long? __________ Aided by drugs? ______
Nightmares and Dreams:
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Recurrent Dreams:
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Unconcious habits:
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Fear of unknown origin:
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Obsessional acts:
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Morning/ Evening Depression:
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SECTION ELEVEN: CLIENT’S SEXUAL LIFE

When informed about sex? _______ By whom? _________ How? ________
Masturbation: ____________________ Homosexuality: ____________________
Menstruation History: First period _________ Duration _______ Painful _______
How did you feel on the onset?
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How did client regard sex?
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Conflict between sexual behavior and beliefs?
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Intercourse Frequency _______ Satisfaction _________ Contraception ___________
Venereal Disease _______ Heterosexual practices outside marriage _____________

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 SECTION TWELVE: MARITAL HISTORY

Spouse Name: ______________________ Occupation: ___________________

Spouse attitude towards client: ___________________________________________
Client’s attitude towards spouse: _________________________________________
Married duration: ___________ compatibility ___________ Abortions ________
Miscarriages ________ Desire or frigidity: _______________________________
Premarital sex contact: ________________________________________________
Client’s children:
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Attitude towards children:
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Children attitude towards client:
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