CASE HISTORY

WHAT IS CASE HISTORY ?

Case History is the record of the client's life; it allows a

clinician/therapist to understand who the client is,where the client has
come from, and where the client is likely to go in the future.

The history is the client's life story told to the clinician/therapist in the
client's own words from his/her point of view.

The history includes information about the client obtained from other
sources, such as a parent or spouse.
 A. DEMOGRAPHIC DETAILS
• Name - Institution of
assessment -
• Age - Date of Assessment -
• Birth date - Informant - If any
• Gender - Reason for referral -
• Education -
• Occupation -
• Marital status -
• Languages spoken -
• Religion -
• Residence -
 CASE HISTORY

Chief complaints

• The chief complaint in patient's own words (verbatim) , stating why he

or she has come or been brought in for help.
• It should be recorded regardless of how bizarre or irrelevant it is, should
be recorded verbatim in the section of chief complaint.
• The complaint should be noted with their onset duration.
• Examples of chief complaints:
• I feel I am going mad.
• I am angry all the time.
• People are trying to drive me insane.
• I am having thoughts of wanting to harm myself since the past 2 days.
 How to ask for chief complaints?

What brings you here?

How can I help you?
What seems to be your concern?
Can you tell me since when you're feeling this way?

Now can you give some examples for the questions you
would ask?
 H I S T O RY O F P R E S E N T I L L N E S S

• The history of present illness provides a comprehensive and chronological

picture of the events leading up to the current moment in the client's life.
• This part of the history is probably the most important part as it includes:
• Onset of the concerns
• Precipitating factors
• Duration
• Intensity
• Past precipitating events
• Severity

The more detailed the history of the present illness, the more likely the
clinician/therapist is able to help the individual with the concerns.
 Past Illness

Psychiatric Medical Substance history

Any past psychiatric Any specific Any history of
illness or episodes medical condition consupmtion of substance
in the past

The patient's symptoms, extent of incapacity, type of treatment received, length

of each illness, effect of each treatment, any specific complications needs to be
recorded for all the above three mentioned areas
 Family history
A brief statement about any psychiatric illness, medical illness,
hospitalization,treatments of the client's immediate family members
should be placed in the family history

The family history should also include the relationship the client shares
with his/her family.

Others areas that need to be covered in family history is how is the attitude
of the client towards his family and siblings?, who is the client closest to ?,
How is his relationship with his siblings?, who does the client feel more
similar to in the family any why?
 Genogra
m
Genograms are a visual representation of a person’s family,
relationships between members, and medical and mental
health histories. It is more in-depth than a family tree
because it provides more extensive information about the
family and each member.
Personal
History
01 02
Prenatal and Perinatal Early childhood

03 04
Middle &Late childhood Adulthood
 How to ask personal
history?
• Was your delivery normal or cesarean ? any complications during the delivery?
(could be asked to the informant).
• Was the baby born at full term, or was he or she premature?
• Was the baby's birth weight within a normal range for gestational age?
• How was the mother's health during pregnancy?
• Did the child experience any developmental delays or milestones reached within
the expected range?
• How was the behavior of the child as kid ?/ how were you as a kid?
• How is the child doing academically? What are their strengths and weaknesses?
• What extracurricular activities or hobbies does the child participate in, if any?
• Does the child have any friends or social groups they belong to?
• Does the person enjoy working in his/her current job?
• Is the person in a relationship currently or has been in past relationships?
• Does the person have any hobbies or interests outside of work?
 Day to Day functioning

Biological Functioning :
Sleep : How is the sleep pattern of the client, is he/she sleeping on time, the sleep
schedule
Appetite: Any changes in appetite, excessive eating or not eating at all
Physical discomfort: Any physical concerns

Social Functioning:
Personal and social interaction: The client's interaction with people around him, his
friends and family members, is the client able to reciprocate socially in an
appropriate manner.
Personal hygiene: Is the client able to take care of himself independently or needs
assistance.
 Occupational History

• What is the person's current occupation and job title?

• Has the person experienced any job-related stress or burnout?
• Does the person feel satisfied with their current job and work-
life balance?
• Does the person have any future career goals or aspirations?
 Marital History & Relationship History
A marital history typically includes a record of a person's marriages and significant
romantic relationships, as well as any relevant information about those
relationships.

Some of the information that may be included in a marital history includes:

• Marital status: Whether the person is currently married, divorced, separated, or
widowed.
• Spouse/partner information: The name and basic demographic information
about each spouse or partner, including age, and any relevant health or
medical information.
• Children: The number and ages of any children born or adopted.
• Any past relationships before the current relationship
• Relationship milestones: Significant milestones in each relationship, such as
getting engaged, or getting married.
Educational history
• Did the person have any significant experiences or
challenges related to their education, such as
academic struggles or discrimination?
• What was the person's academic performance like?
• Does the person have any future education goals or
aspirations?
• Does the person feel satisfied with their education
and how it has contributed to their life and career?
• How was the person's experience in his school/
college?
 Personal beliefs and social
behavior

Religion Social Activity Current living situation

Details regrading the client's religious belief, his/her social activities and interaction can be
included.The client's current living situation with family or alone, with friend or rent
 Other Important
Information

Premorbid History Sexual History Fantasies &Dreams

Premorbid history refers A sexual history is a Fantasies and dreams can

to a person's medical, collection of questions provide valuable insights into a
psychiatric, and social about a person's sexual person's thoughts, emotions,
history before the onset and experiences, and may be
health and behaviors.
of a particular illness or relevant to their concerns
condition.
 Case History taking in child counseling

Some of the concerns faced by children

• Peer Pressure and Social Challenges
• Social Anxiety
• Eating disorder
• Anger outbursts or temper tantrums
• Family issues
• Anxiety
• Academic concerns
• Nightmares
• Bullying
• Difficulty in forming social relationships
Now can you suggests some of the concerns children face ?
 Specific Areas to cover in child counseling

Some areas to covered more in depth for children :

• Developmental history: Ask about the child's developmental milestones, including when
they first walked, talked, and reached other developmental milestones.
• Family history: Inquire about the child's family structure, including their relationships with
parents, siblings, and other caregivers. Ask about any significant events or changes in the
family that may have impacted the child.
• Educational history: Gather information about the child's academic history, including their
performance in school, any learning disabilities, and their relationship with teachers and
peers.
• Social history: Ask about the child's social life, including their relationships with friends,
participation in extracurricular activities, and hobbies.
• Emotional and behavioral history: Inquire about the child's emotional and behavioral
history, including any previous counseling or mental health treatment, as well as any
significant life events or traumas that may have impacted their mental health.
• Current concerns: Ask about the child's current concerns and issues, including any
symptoms or behaviors that are causing distress.
 How you can cover the case history for
children?
• How long has the child been experiencing the presenting problem?
• What is the child's developmental history, including important milestones and developmental
concerns?
• How does the child feel about school, their academic performance, and relationships with
teachers and peers?
• What is the child's relationship like with their family members and caregivers? Are there any
significant family dynamics that may be impacting the child's mental health?
• How long has the child been exhibiting these behaviors, and have they changed in frequency or
intensity over time?
• Are there any triggers or situations that seem to exacerbate the child's problematic behaviors?
• What strategies have been attempted by caregivers to address the child's behaviors, and have
any been successful?
• What sensory sensitivities or challenges does the child experience, and how can these be
accommodated in their daily life?
• What are the child's primary areas of difficulty (e.g. communication, social interaction, sensory
processing)?
•
 Concerns faced by
adults
Work-related Stress

Financial stress

Uncertainty about career

Loneliness, sadness,anxiety,burnout

Relationship stress

Self-esteem issues, weight concerns

Major life events

 Case History taking for adult counseling
• Depending upon the presenting concerns one can take case history accordingly. Some
examples:
• What is your current concern or reason for seeking counseling?
• Any recent changes or stressors related to housing or finances?
• When did you first notice feelings of sadness or depression?
• What is your history of substance use or addiction, including any past or current patterns of
use?
• Have you shared about your concerns with someone?
• How long have you been experiencing theses concerns?
• How does your stress affect your mood and emotions? Have you experienced any changes in
your mood or anxiety levels?
• Have you noticed any physical symptoms related to your stress, such as headaches,
stomachaches, or difficulty sleeping?
• Are there any other factors in your life that contribute to your stress, such as work or family
issues?
• What are your current coping mechanisms, and how effective have they been in managing
stress and emotional challenges?
Concerns faced by geriatric
population

• Physical Health Issues

• Memory loss
• Social isolation, or the loss of loved ones
• Caregiver Stress
• Social Isolation and Loneliness
• Elder Abuse
• End-of-Life and Advance Care Planning
• Financial Insecurity
 Case history taking for geriatric
counseling
• Can you tell me about your medical history, including any chronic conditions,
medications, or recent hospitalizations?
• Have you noticed any changes in your memory or thinking abilities?
• How has your physical health affected your daily life and activities?
• Are you experiencing any pain or discomfort?
• How has your social support network changed in recent years? Do you have family and
friends who you can rely on for help or emotional support?
• Have you experienced any significant life changes or losses, such as the death of a
loved one or retirement?
• Are you experiencing any difficulties with daily living activities, such as bathing,
dressing, or cooking?
• How are you currently managing your finances and household responsibilities?
• Have you noticed any changes in your mood or emotional well-being, such as feelings
of sadness or anxiety?
 Concerns faced by individuals who are
grieving
• Intense emotional pain
• Change in Appetite, headaches
• Social isolation
• Relationship issues
• Unhealthy coping mechanisms
• Feelings of guilt
• Anxiety, fear
 Case History taking for Grief
Counseling
• Can you tell me about the person you lost and your relationship with them?
• When did the loss occur and how did it happen?
• How have you been feeling since the loss?
• Have you experienced any physical or emotional symptoms since the loss?
• How has your grief affected your daily life and activities?
• Have you received any support from family and friends? How have they been
helpful or unhelpful in your grieving process?
• Are there any unresolved issues or conflicts related to the loss?
• Have you experienced any significant life changes or transitions since the loss?
• Have you experienced any other losses or difficult life events in the past?
• What are your expectations or goals for the counseling process?
 Concerns faced by individuals who are married or
couples

• Communication difficulties
• Intimacy and Sexual Concern's
• Trust and Infidelity
• Differences in Values and Goals
• Stress and Work-Life Balance
• Financial Issues
• Cultural or Religious Differences
• Lack of Emotional Connection
 Case History taking for couple/marriage
counseling
• Can you tell me about the history of your relationship, including how you met and your initial
attraction to each other?
• What are the current issues or conflicts in your relationship that have led you to seek counseling?
• How have you been communicating with each other regarding these issues?
• How have you been addressing disagreements or conflicts in the past?
• Have you tried any strategies to improve your relationship in the past? If so, what were they and
how successful were they?
• How have external factors, such as work or family stress, impacted your relationship?
• What are your goals for the counseling process and what do you hope to achieve?
• How would you describe your individual personalities and communication styles?
• Have you experienced any significant life changes or transitions recently that have impacted your
relationship?
• Have you received any previous counseling or therapy, individually or as a couple, and what was
your experience with it?
 Concerns of individuals with trauma
• Flashbacks,nightmares
• Emotional numbness
• Emotional distress
• Avoidance of places or triggers
• Trust and safety concerns
• Hyperarousal
• Difficulty in communicating emotions
 Case History taking for trauma
counseling
• When taking a case history for trauma counseling, it is important to be sensitive and
mindful of the client's experiences and emotions.
• Ask the client to describe the traumatic event(s) they experienced or witnessed.
• Explore the client's current symptoms, including any physical symptoms (such as
headaches or fatigue), emotional symptoms (such as anxiety or depression), and
behavioral symptoms (such as avoidance or hyperarousal).
• Inquire about the client's history of exposure to traumatic events, including any childhood
traumas, previous experiences of violence, or natural disasters.
• Ask the client about their current coping strategies and how they have dealt with the
traumatic event(s) in the past.
• Ask the client about how the traumatic event(s) have affected their daily life, including
their relationships, work, and other activities.
• Ask the client about the intensity of the symptoms?
 • Depression and Anxiety
• Substance Abuse and
Addiction
• Trauma and Post-Traumatic
Concerns of individuals entering Stress Disorder (PTSD)
group therapy • Grief and Loss
• Self-Esteem and Body Image
• Eating Disorders
• LGBTQ+ Support and
Identity Exploration
• Relationship and
Interpersonal Issues
 Case history taking for group therapy ?
• What brings you to group therapy?
• What are your expectations from group therapy?
• Have you been in group therapy before? If yes, what was your
experience?
• What are your personal goals for group therapy?
• What challenges are you currently facing in your life?
• How do you currently cope with stress or difficult situations?
• What are your strengths and resources that you can bring to group
therapy?
• How do you feel about sharing your personal experiences and thoughts
with others in the group?
• What is your communication style, and how do you handle conflicts with
others?