Assessmest

Brief of life

          SI. No--------------------                                                Date---------------

1.                 Interview give by :

2.                 Interview taken by :

3.                 Source of reference :

4.                 CLIENTS NAME:

(a)  Age  :                                         Date of birth :

(b)  Sex   :                                       

5.      Address :                                      Phone :

(a)  Present :                                     Date of birth :

    (b)  Permanent   :

5.                 FATHER/GURDIANS NAME:

Age :

Educational qualification :

Occupation:

(a)     Government service (specify) :

(b)     Semi-Government service (specify):

(c)     Private service (specify) :

(d)     Business service (specify) :

(e)     Any other (specify) :

7.      MOTHER`S NAME:

Age :

Educational qualification :

Occupation :

(a)     Government service (specify) :

(b)     Semi-Government service (specify):

(c)     Private service (specify) :

(d)     Business service (specify) :

(e)     Any other (specify) :

8.     Consanguinity (marriage among blood relation) :

9.     SIBLINGS  :

	1	2	3	4	5	6	7	8	9	10	11	12
Age
Sex
Education

10.                        Other members living together :

11.                        CHILD`S BIRTH HISTORY :

(a)     Prenatal :

(b)   Type of delivery :

(i)                    Forceps :

(ii)                 Caesarian :

(iii)              Normal :

     12.  (a)   Did the Child have any difficulties in the first four weeks ?

            (b)   Did the child suflet from any serious illnesses ?

     13.  MILESTONE DEVELOPMENT OF THE CHILD ?

(a)   Head Controlled :                     (e)  Walked alone :

          (b)   Sat :                                          (f)  Spoke  :

         

(c)   Crawled :                                  (g)  Present condition :

(d)  Stood with Support :

14.  GENERAL BEHAVIOUR :

          The will include problems associated with :

(a)   Appetite :                       

          (b)   Sleep :                                               

         

(c)   Play :                                

(d)  Fear :

15.  TEMPERAMENT OF THE CHILD :

          The will include problems associated with :

(a)   Cheerful :                       

          (b)   Jolly :         

          (c)    Quiet :                           

         

16.  DAILIY LIVING ACTIVITIES:

(a)   Toileting :                                 (d)   Grooming : 

         

                   (b)   Eating :                                               (i)   Brushing :

                   (c)    Dressing:                                           (ii)   Cleaning :

                                                                                       (iii)  Combing :

17.  COMPREHENSION :

(a)   Expression :                                                

                   (b)   Reception : 

18.  MENSTRUATION :

19.  School Performance :

(a)   Does the child attend school ?                                       

                   (b)   First admission in school including age :

                   (c)   Progress year by year :                     

20.  To whom was the child shown for the above problem ?

21.  PRESENT PROBLEM ?

(a)   By parents :                             

                   (b)   By Client :

22.  Test administered ?

23.  Result of the Test :

24.  Formulation and diagnosis :

25.  Present Problems Observed  :

26.  Observations during testing Period :

27.   Management programme and advice to the parents :

SUMMARY OF THE CASE AND CONCLUSIONS