Directorate General of Special Education Department

31 Sher
her Shah Block, New Garden Town
(042) 99231366
sed.punjab.gov.pk/academics

CASE HISTORY FORM FOR

Bio Data
Student’s Name: _____________________
_________________ Admission Date: _______________
Age: ______________ Gender: _________________
[Photo Graph]
Date of birth: ______________ Birth order: _________________
Religion: ______________ Class/ Grade: ________________
Contact No.: ______________
Home Address: _________________________________________________
_______________________________________________________________
_______________
Informant Name: __________________________
_______________________________ (relationship
relationship with child) _____________

Type of Disability (Check

Check all that apply
apply):
Intellectual Disability (ID) Global Developmental Delay (GDD)
Autism Spectrum Disorder (ASD) Down Syndrome (DS)
Micro Cephalic Hydro Cephalic
Attention Deficit/Hyper Activity Disorder (ADHD) Cerebral Palsy (CP)
Visual Impairment (Total/ Partial / Low vision) Hearing Impaired
Learning Disability: If yes tick the relevant
(Dyslexia/ Dyscalculia / Dysgraphia / Dyspraxia)

Mention Additional /Multiple disabilities (If Any): ____________________________________

____________________________

SECTION-I
Family History

Fathers’ Name __________________

____________________________ Age: ________________
Education: ____________________________ Occupation: ________________
___________
Monthly Income: __________________
_____________________ No of dependents: _____________
________
Father living or dead:___________________
___________________ If dead age at death: ____________
Cause of death: ________________________
Any history of physical & psychiatric illness:
illness ______________________________________
Attitude towards target child: (Loving
Loving / Overprotective / Careless / Harsh / others)) __________
Attitude towards other children: (Loving/
Loving/ Overprotective/ Careless/ Harsh/ others)
others) __________
Relationship with spouse: (Satisfactory/Understanding/Conflicting/
Satisfactory/Understanding/Conflicting/ Separated/ Divorced)
Divorced _____
Personality Characteristics:
(Friendly / Cooperative / Optimist / Flexible / Stubborn / Aggressive / Non-cooperative/
Non
Introverted/ Pessimistic/ any other) _____
____________________________________________
__________________________________________
History of abuse / drug abuse ___________________________________________________
 Directorate General of Special Education Department
31 Sher
her Shah Block, New Garden Town
(042) 99231366
sed.punjab.gov.pk/academics

Mothers’ Name ____________________________ Age: ________________

Education: ____________________________ Occupation: ________________
Monthly Income: _____________________ No of dependents: _____________
Mother living or dead:___________________ If dead age at death: ____________
Cause of death: ________________________
Any history of physical & psychiatric illness: ______________________________________
Attitude towards target child: (Loving / Overprotective / Careless / Harsh / others) __________
Attitude towards other children: (Loving/ Overprotective/ Careless/ Harsh/ others) __________
Relationship with spouse: (Satisfactory/Understanding/Conflicting/ Separated/ Divorced) _____
Personality Characteristics:
(Friendly / Cooperative / Optimist / Flexible / Stubborn / Aggressive / Non-cooperative
Non /
Introverted/ Pessimistic/ any other) __________________________________________
______________________________________________
History of abuse / drug abuse ___________________________________________________
Reaction pattern to stress (Specify behavioral & emotional symptoms):
___________________________________________________________________________
___________________________________________________________________________
________________________________________________________________________
Are parents living together / separated / divorced? ___________________________
___________
Is child living with both parents, if no, with whom? ________________________
__________________________________
Is child living with step father/ step mother? ________________________________________
___________________________________
Siblings’ Information
No.
o. of Siblings: __________ No. of Brother/s: __
_____________
___________ No. of Sister/s: _____________
__
Interpersonal Relationship with Siblings: ____________________________________________
_______________________ __________________
Any form of disability or chronic disease present in siblings: Yes / No (If yes please describe)
__________________________________
_____________________________________________________________________________
_______________________
History of any kind of verbal / physical / Sexual abuse with the child
child: Yes / No (If yes please
describe:
___________________________________________________________________________

Overall Pattern of Family Relationship

Alliance Communication Exclusive Tension Criticism

Consanguinity

1st Cousin 2nd Cousin Other relatives No relation

 Directorate General of Special Education Department
31 Sher
her Shah Block, New Garden Town
(042) 99231366
sed.punjab.gov.pk/academics

SECTION II
Birth History

Mother’s age & health at the time of this pregnancy

pregnancy: _________________________________
Was there any illness, injuries, bleeding, or any complication during this pregnancy? Yes / No
(If yes please describe:
___________________________________________________________________________
Duration of pregnancy: ________________ Emotional
Emotional status during pregnancy: _____________
__
Duration of labor: ________________
Type of Delivery: Normal C
C- section Vaginal Breech
Birth Place:: _______________ 1st Cry: Yes / No Breathing problem: Yes / No
Anoxia: Yes / Noo Birth weight: _________ Jaundice: Yes / No
Any Fever: Yes / No (if yes) ____________
__________ Birth injury: Yes / No (if yes) ________________
__________
Congenital abnormalities: Yes / No (if yes) _______ Convulsion: (if yes) ___________________
______________
Any other illness: ______________________________________________________________
Did your child bottle or breast fed?____________ How long (specify
ify duration) _____________
Did your child had any sucking/ feeding difficulty Yes / No (if yes):______________________
______________________

Developmental Milestones

Physical Millstones Achieving Age

Neck holding
Sitting
Crawling
Walking
Babbling
Speech (single word)
Two words speech
Talking (complete sentence)
Eating without help
Dressing without help
Taking bath without help
Bladder Bowl control
 Directorate General of Special Education Department
31 Sher
her Shah Block, New Garden Town
(042) 99231366
sed.punjab.gov.pk/academics

SECTION III

Medical History/ Health Information

Has your child had any of the following?

Meningitis Mumps Measles Head injury Hepatitis
T.B Polio Asthma Chicken pox Whooping
Coughs
Cleft Cleft Epilepsy Seizures
Lips Palate
Vision Squint Cataract Glaucoma Ear Infection
Problem
High grade fever (with /without fit) Non
Any other Health issue: __________________________________________________________
______________________________________________________
Allergies: Yes / No (if yes specify)) ________________________________________________
___________________
Has completed vaccination course?? Yes / No
Has completed Covid-19
19 vaccination course? Yes / No
age: ____________________________________________
Any health issue with approximate age _______________________________________
If yes, duration of care: _______________________ Length of hospital stay: _____
______________
Medication currently: Yes / No (If
If yes, name of medicine(s) ____________________________
___________________
Psychosomatic complaints: Yes / No (if yes specify) ___________________________________
Emotional and Behavioral Pattern
Thumb sucking Nail Biting Finger Chewing
Teeth grinding Temper tantrums Hyperactivity
Enuresis (Day/Night) Stuttering Stammering
Rigidity / stubbornness Anxiety Fears
Danger Recognition Masturbation Stealing
Argumentativeness Aggressiveness
(Physical / verbal)
Is your child manageable at home? Yes / No / with assistance
Is your child manageable outside of the home? Yes / No / with assistance
Repetitive behaviors: Yes / No (if
if yes specify) ______________________________
_____________________
Any other Behavioral issue: (if yes specify) ___________________________________
Social Skills
Does child prefer to play? (Check all tha
that apply):
Alone With other With older With younger
children children children
 Directorate General of Special Education Department
31 Sher
her Shah Block, New Garden Town
(042) 99231366
sed.punjab.gov.pk/academics
Does child? (Check all that apply)
Avoid eye contact Dislike being touched or cuddled
Appear self-centered Interrupt others frequently during conversation
Fail to take turns during conversation
Shows little or no interest in what the other person has to say
Fail to use polite form of communication (Saying please/sorry/thank you/Hello/Good bye)
Communication Skills
How does your child communicate?
communicate (e.g. uses words, phrases, sentences, sign language, gestures):
gestures)
please specify: ___________________
_______Understands / follows simple directives:: Yes / No ______
What languages are spoken at home? __________What
__________ languagee does child speak? __________
Understanding of child’s expressive speech by:
Teacher: _________________ Mother
Mother: __________________ Father: ________________
_____________
Less familiar people:: _______________ Any other: _________________
Identify situation / setting at which child feels difficulty in communication
communication:
Home ____________________ School ____________________ Friends __________________
________
Social Gathering ____________Eve
Every where _______________Any other _________________
_______________
Other speech problem
roblem related to articulation, voice, fluency (if any) ____________________
Has a speech-language
language pathologist (SLP) provided therapy services to the child? Yes /No
If yes please specify:
When? ____________________________ Duration ____________________________
__________________________________
Why? ______________________________Where? ___________________________________

SECTION IV
Educational History
Mention the previous school if attended (if any) ____________________________________
Age at the time of admission: ______________ class of admission: ____________________
Progress in school work (Poor/ Satisfactory/ Good) _____
_________________________________
___________________________
Grades repeated? if yes, why ? ________________ Reason of withdrawal
drawal __________________
________________

Relations with teacher: Good satisfactory Poor

Relations with peer(s): Good satisfactory Poor

 Directorate General of Special Education Department
31 Sher
her Shah Block, New Garden Town
(042) 99231366
sed.punjab.gov.pk/academics

Performance Level
Comments

Average

Average

Average
Academic Area

Above

Below
i. English
Reading
ii. Urdu
i. English
Writing
ii. Urdu

Numerical Ability

Any other (General Knowledge /

Science / Social Studies etc.)

Any additional support (coaching / Tuition / academy / remedial class)) provided or not:
not if yes
mention the hours: ____________
___________________ Classroom participation: Active / Passive
Attitude towards studies: _____________________
_____________________________________________________
____________________
Interests & Hobbies
Likes: Dislikes:
__________________________________ _______________________________________
__________________________________ _____________________________________
___________________________________
Leisure time activities: ________________________________________________________

______________________________
_________
Psychologist’s Name & Signatures:

Date: ______________