C LI N IC O S O C IA L C A S E

A. HISTORY TAKING :

A.1 IDENTIFICATION DATA :

_ _ _ _ _ Ag e: _ _ Se x: _ _ __
Na me :_ _______

ation :--------
_ _ _ _ _ _ ___ Occup
Re ligion: _

- - - - - - ------ -----
Address = - - - - -

__ _ __
Marital St atu s: _ _ _

NG CO M PL AI NT S (In ch ro no lo gi ca l .o rd er )
A.2 PRESENTI

LNESS / SYMPTOMS :
A.3 HISTORY OF PRESENT IL

A.4 PAST HISTORY :

◄
 FAMILY HISTORY:

A.6 PERSONAL HISTORY :

A.7 NUTRITIONAL HISTORY :

A.8 OCCUPATIONAL HISTORY :

A.9 ENVIRONMENTAL DATA :

A.9.1 HOUSING :

A) Type of Housing :

B) Number of rooms & Size:

C) Per capital Floor Space

D) Light during day : Natural / Artificial

E) Fuel used in cooking : Wood/coal/kerosene/cowdung/others.

F) Ventilation :

6
 11111111

A.9.2 WATER :

a) Source : Municipal Tap / Other (Specify)

b) Supply : Intermittent/ Continuous

c) Storage : Earthen pots / Vessels / Others

A.9.3 SANITATION :

a) Method of waste water disposal:

b) Method of solid waste disposal :

c) Method of excreta disposal :

d) Toilet: Separate/ Common I Outdoor:

e) Animals kept in the house : Yes / No

if yes, specify :
A.10 SOCIO ECONOMIC DATA:

A.10.1 SOCIO ECONOMIC CLASS:

(According to modified Kuppuswamy scale

A.10.2 TYPE OF FAMILY: Joint/ Nuclear.

7
 A.10.3 SOCIO ECONOMIC DA1'A

How Immunization
Relationship Marital
Sr. Age Sex long Education Occupation Income Status
Name to H.O.F. Status
No. staying with date

00
B. EXAMINATION :
8.1 GENERAL EXAMINATION :
8.1.1 Buil t:
8.1.2 General Nutr ition :
8.1.3 Dec ubit us:
8.1.4 Club bing :
8.1.5 Cya nosi s:
8.1.6 Pall or:
8.1.7 Lym phad enop athy :
8.1.8 Oed ema :
8.1.9 Skin :
8.1.10 Vert ebra l Colu mm :
8.1.11 Thic kene d Nerves & Join ts :
8.1.1 2 Puls e:
8.1.1 3 Res pira tion :
8.1.1 4 Bloo d Pres sure :
8.1.1 5 J.V~P. ·
8.1. 16 Anth ropo met ry :

B.2 SYSTEMIC EXAMINATION :

B.2.1 ABDOMEN :

B.2.1.1 Inspection :

I 9
9.2.1.2 PALP ATIO N:
a) Liver
b) Kidne y
c) Splee n
d) Any Othe r

s.2.1 .3 PERC USSI ON :

s.2.1 .4 AUSC ULTA TION :

s.2.2 CAR DIOV ASCU LAR SYST EM :

B.2.2.2 PALP ATIO N :

B.2.2.3 PERC USSI ON :

8.2.2 .4 AUS CULT ATIO N:

B.2.3 RESP IRAT ORY SYST EM :

B.2.3.1 Inspe ction :

10
 ◄

B.2.3.2 PALPATION ;

B.2.3.3 PERCUSSION :
B.2.3.4 AUSCULTATION ;

8.2.4 CENTRAL NERVOUS SYSTEM :

a) Consciousness:
b) Memory :· Past : Present
c) - Orientation: Time, Place, Person.
'

d) . Speech: .
e) Hallucinations & Delusions :
f) Cranial Nerves :

B.2.4.2 MOTOR SYSTEM :

B.2.4.3 SENSORY SYSTEM :

a) Supe_rficial Sensations
b) Deep Sensations
c) . Calf-Tendemess
d) Special Senses

B.2.4.4 REFLEXES:

11

◄
13.z.A,5 QEVELOPMENT MILESTONES _;_
(IN CHILDREN)

plFFERENTIAL DIAGNOSIS_;_
C
INVESTIGATIONS •
D - -!.

i) Blood
ii) Urine

iii) Stool
iv) Radiology
v) Any other {specify}

E DIAGNOSIS:

F TREATMENT GIVEN :

G RESULT:

H ANY ADVICE GIVEN TO PATIENT ON DISCHARGE

12
C SOCIO· CULTURAL PRACTICES IN THE FAMILY:

i) Source of Medical care

a) during minor illness

ii) Practices & prejudices regarding infectious diseases.

iii) Belief and Prejudices regarding

a) Breast-feeding
b) Weaning
c) Introduction of Solids
d) Immunisation
e) •Medicines

f) •Particula_r food articles during pregnancy and illness.

iv) Any other

13
 r,o)(IMATE MONTHLY EXPENDITURE OF THE FAMILY ON
,.ppr.
p.
1. FOO D:-

(a) Pulses and Cereals

(b) Milk

(c) Vegetables, Fruits

(d) Meat, Fish, Eggs

(e) Oil, Ghee

(f) Sugar, Jaggery

(g) Any other

2. Fuel and Lighting

3 Rent

4 Clothing

5 Transport

6 Medicines and Medical Aid

7 Education

8 Recreation

9 Any Other

Total

14
E. APPROXIMATE QUANTITIES OF FOOD CONSUMED BYTHE FAMILY (Per Day)
-
1. Cereals & Millet:-

(a) Rice
(b) Wheat
(c) Millet (Jowar, Bajra, Ragi)
(d) Others (Specify)

2 Pulses:
3 Vegetables :
a) Green Leafy Veg.
b) Roots & Tubers
c) Roots & Tubers

5 Fruits:
5 Milk & Milk Products

6 Meat
7 Chicken (Lean Meat)

8 Fish
9 Eggs:

10 Fat:
a) Oil
b) Ghee/ Vanaspati / Butter

11 Sugar/ Jaggery:

12 Beverages : (Tea/ Coffee)

13 Others (Specify)

Total

15