Al-Shifa Trust, Special School and Center for Rehabilitation

HISTORY SHEET FORM

File No: _____________________
Dated: ______________________

Name _______________________________________________________________ Sex __________________________

Date of Birth _________________________ Age _____________________ Marital Status S M D W Sep
Present Address ___________________________________________________________________________________
Cell No _______________________ Education ___________________ Occupation _____________________________
Father’s Name _______________________ Age _________ Edu ____________ Occ_____________________________
Mother’s Name ______________________ Age __________ Edu ___________ Occ_____________________________
Siblings: M _______ F ________ B.O __________ Children (sons & daughters) ________________________________
Family Structure ___________________________ Head of Family ___________________________________________
Income Group _____________________________ Heritage ________________________________________________
Language _________________________________ Informant’s Name ________________________________________
Referred By________________________________________________________________________________________
Intake by ________________________________________

--------------------------------------------------------------------------
Presenting Complaints (nature of problems, precipitating event, client’s thoughts and feelings about
problems)__________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

History of Problems (duration of problem, change in nature, intensity/frequency of problems, past

problems and manifestation of problem) _________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Prior Treatment (detail of problems, duration, treatment methods, medication, spiritual,
reactions/side effects, medical disease, childhood illness, alcohol/drugs and ECTs) _______________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Family History (migration, birth, marriage, deaths, earning members, behavior and relationship with
family members) ____________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

School History (marks/divisions obtained, school changes, school problems, attitude with peers,
teachers, and extra-curricular activities) __________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Work History (nature of job, reason for job change, quit job, relationships with juniors, colleagues,
and bosses) ________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

History of Friendships (nature & extent of relationships, recreational activities, degree of religiosity,
sexual history, marital, and extra-marital sexual relationships) ________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Childhood Disorders (low intellectual functioning, poor achievements, adaptive behavior problems,
developmental problems, perceptual disability, delayed milestones, language problems and ADHD
problems___________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Orientation (person, place, time) _______________________________________________________

__________________________________________________________________________________
__________________________________________________________________________________

Sleep (insomnia, hypersomnia, nightmares, sleepwalking, disturbed sleep, dreams sleep) ___________
__________________________________________________________________________________
__________________________________________________________________________________

Attention (concentration, memory, forgot things, short terms memory, inattention & impulsivity) ___
__________________________________________________________________________________
__________________________________________________________________________________

Perception (illusions, hallucinations- auditory, visual, tactile, somatic, olfactory) _________________

__________________________________________________________________________________
__________________________________________________________________________________

Thoughts (delusions- suspiciousness, unusual thoughts, disorganized thinking, poor association,

paranoid ideation, feeling of grandiosity) _________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Affects (crying spells, depressed mood, guilt feelings, lack of interest, hostility, suicidal, low mood,
fatigue, isolation, low self-esteem) ______________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Behavior (mute, talkative, abusive, restless, assaulting, destructive, excited, mannerism, body
movement & muscle retardation) _______________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Anxiety (tension, nervousness, phobias, obsessions/compulsions, traumatic events, panic attacks) ___
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Somatoform (conversion, hypochondriasis, other somatic complaints) _________________________

__________________________________________________________________________________
__________________________________________________________________________________

Psychosexual (gender identity, paraphilias, psychosexual dysfunctions) ________________________

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Psychosomatic (obesity, headaches, painful menstruation, skin disorders, asthma, ulcers, nausea, and
vomiting) __________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Family Psychopathology (nature, history, treatment of mental disorders in members of patient’s

family) ____________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Personality Traits (paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic,

avoidance, dependent, obsessive compulsive, passive aggression) _____________________________
__________________________________________________________________________________
__________________________________________________________________________________

Interview Information (open, secretive, anxious, relaxed, withdrawn, cooperative, and aggressive)
__________________________________________________________________________________
__________________________________________________________________________________

Strengths (degrees of insight, motivation level, intellectual, level, others talents, circumstances) ____
__________________________________________________________________________________
__________________________________________________________________________________

Tentative Diagnosis _________________________________________________________________

Recommendations (List of tests) _______________________________________________________
Termination ______________________________________ Date ____________________________

(Examiner) ______________________________________
(Signature)