Clinico-social-case format (Index case- Adolescents)

1. Identification & demographic details:

Name: 

Age: 

Sex: 

Religion and caste:

Education: 

Address: 

Nearest health facility: 

2. Presenting/ Chief complaints:

Complaints of____________since______days/ months/ years. (In chronological order)

(Complaints are mainly 

3. History of presenting illness:

My patient was apparently alright then he developed _____________(name of the symptom) which was insidious/ sudden in onset, progressive/ non-progressive in nature. (describe each symptom in detail with treatment history if taken). There is no history of _______________________. (Ask & write the negative history based on probable causes.)

4. Past history: 

Write down if any history of past surgeries, illnesses, blood transfusions, allergies, or trauma.

Immunization history: ________________________

5.Menstrual history: 

(if female patient)

Menarche attained: Yes/ No

Age of menarche___________years

Menstrual cycle: Regular/ irregular

Menstrual irregularities: Dysmenorrhea/ Menorrhagia/ Metrorrhagia/ Others_________

Passing clots: Yes/ No

Menstrual hygiene/ Use of Sanitary pads: Yes/ No

H/o white discharge P/V: Yes/ No

6. Reproductive health issues:

Have you attended any workshop/ lecture/ health talk pertaining to sex education: Yes/ No

Have you heard about sexually transmitted infections/ HIV & AIDS: Yes/ No

7. Personal history:

Diet: Veg/ Mixed/ Vegan

Appetite: Normal/ Increased/ Decreased

Food fads: Yes/ No

If yes specify: ____________________

Bowel & bladder: Regular/ Irregular

Sleep: Normal/ Increased/ Decreased

Physical exercise: Regularly/ Infrequently/ No

Outdoor playing activities: Yes/ No

Addiction: Yes/ No

(If yes, then specify Gutkha/ Pan-mashala/ Tobacco chewing/ Smoking/ Alcohol/ IV drugs)

Duration: ______________________

Reason for initiation: __________________

8. Family history: 

Family type: Nuclear/ Joint/ 3 generation

Family composition (draw a family tree)

Any history of consanguinity: Yes/ No

Family relationships: Good/ Not good

The response of family towards the illness:_____________

(No need to write if it is included in the family details)

9. Environmental history:

Housing:

Toilet:

Waste disposal:

Drinking water:

Animals/ pets:

Occupational environment:

(No need to write if it is included in the family details)

10. Socio-economic history:

Interaction with society: Yes/ No

The response of society towards the person: Good/ Bad/____ 

Presence of stigma: Yes/ No

if yes specify____________________

Participation in festivals, marriages and other social activities & involvement in social groups: Yes/ No

Total family income:______________

Expenditure on diet and medical care:__________

Savings or debts_____________________

Family tensions due to the economic situation: Yes/ No

(No need to write if it is included in the family details)

11. Nutritional history (as relevant to the case):

Calculation of calories, carbohydrates, proteins & fats (& salts) being supplied to the person by 24-hour diet recall method (tabular format for breakfast, lunch, evening snacks & dinner) and required amount by the person through diet. Mention the deficiency or excess.

(No need to write if it is included in the family details)

12. Psychosocial history & behavioral issues:

(To be asked from parent/ Guardian of the adolescents)

Has she/ he ever indulged in anti-social/ criminal activities (eg. theft, etc.): Yes/ No

Is the adolescent's interaction with peers/neighbors/ opposite sex normal: Yes/ No 

If no, specify:___________________

Is he/ she currently going to school: Yes/ No

If yes, does he/ she has any difficulties in the school/ studies: Yes/ No

If yes, specify:_________________________

Mental adjustment to physiological changes in the body: Yes/ No

13. General physical examination:

Vitals:

Blood pressure (BP): ___________ mm Hg, 

Pulse rate(PR): __________ beats/ min

Respiratory rate (RR): __________ cycles/ min

Temperature: ___________ degree F

Pallor: Yes/ No

Icterus: Yes/ No

Clubbing: Yes/ No

Cyanosis: Yes/ No

Lymphadenopathy: Yes/ No

Edema: Yes/ No

Anthropometry: 

Built: 

Nourishment:

Height: _________m

Weight: ________kg

BMI:__________ kg/ m2

Head to toe examination:

General cleanliness: Good/ Bad

Hair: clean/Unclean/ Combed/ Uncombed

Eye: Vision: Normal/ Decreased; Using spectacles: Yes/ No

Ear: Hearing: Normal/ Decreased; if decreased ,type of hearing loss: Conductive/ SNHL/ Mixed; Ear discharge: Yes/ No

Oral hygiene: Good/ Poor

No of teeth:______

Skin: Normal/ Abnormal (papules/ pustules/ eczema/ macules/ patches, etc.)

Any other significant findings:___________________

14. Systemic examination:

Respiratory system:

Inspection:

Palpation:

Percussion:

Auscultation: 

Cardiovascular system:

Inspection:

Palpation:

Auscultation: 

Gastrointestinal system:

Inspection:

Palpation:

Percussion:

Auscultation: 

CNS examination:

Inspection:

Palpation:

Musculoskeletal system: 

Inspection:

Palpation:

Signs of puberty:

For boys: Voice change/ Testicular enlargement/ Pubic & axillary hair/ Facial hair

For girls: Breast enlargement/ Pubic & axillary hair

Provisional clinical diagnosis:

Laboratory investigations:

(already done and planned in future)

Clinico-social diagnosis:

This is the family of Mr.____________residing in ________ (name of the area), having nuclear/ 3-generation/ joint family,  belonging to socioeconomic status class __________ according to _____________ (name of the classification), a BPL/ APL card holder. The health problems, health demands & health needs of the family are _______________________. (Disease with/without complication, Social problem, Mental problems). The vulnerable individuals identified in the family are ________ (why are they vulnerable?)

Comprehensive management plan: