7/28/2019 Case Study Form

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Case Study Form

S. No______________________________

Name________________________________________________________________________________

Sex__________________ Age_______________

Fathers Name_________________________________________________________________________

Occupation of Father____________________________________________________________________

Total monthly income of the family (from all sources) _________________________________________

Mothers Name________________________________________________________________________

Address for correspondence______________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Permanent Address_____________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Phone No.________________________

Mobile No.________________________

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Details of the Problem

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Name and Address of the person giving information of problem

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Phone No.________________________

Mobile No.________________________

Problem as Reported___________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

General Introductory Details about the Subject

Related to Birth

Birth Place____________________________________________________________________________

Mothers health at the time of birth________________________________________________________

Childs health at the time of birth__________________________________________________________

Any difficulty at the time of birth__________________________________________________________

Any disease in childhood_________________________________________________________________

Any accident in childhood________________________________________________________________

Any other important incidents in childhood__________________________________________________

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Related to Development

Age of sitting__________________________________________________________________________

Age of standing________________________________________________________________________

Age of walking_________________________________________________________________________

Age at which the child started speaking_____________________________________________________

Problem in childhood (speaking) __________________________________________________________

Present health of the child_______________________________________________________________

Details of the Family

About the Father/guardian

Age of the father/guardian_______________________________________________________________

Occupation of the father/guardian_________________________________________________________

Education of the father/guardian__________________________________________________________

Interest of the father/guardian towards his occupation________________________________________

Health of the father/guardian_____________________________________________________________

Nature of the father/guardian_____________________________________________________________

Interest of the father/guardian in the child__________________________________________________

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About the Mother

Age of the mother______________________________________________________________________

Occupation of the mother________________________________________________________________

Education of the mother_________________________________________________________________

Interest of the mother towards her occupation_______________________________________________

Health of the mother____________________________________________________________________

Nature of the mother___________________________________________________________________

Interest of the mother in the child_________________________________________________________

Expectations of the mother from the child___________________________________________________

Relation of mother with the father_________________________________________________________

About the Siblings

Total no. of brothers and sisters___________________________________________________________

Brothers______________________________________________________________________________

Sisters________________________________________________________________________________

Order of the child_______________________________________________________________________

Name, ages and sex of other family members related with the child:

1. ______________________________________________________________________________2. ______________________________________________________________________________3. ______________________________________________________________________________4. ______________________________________________________________________________5. ______________________________________________________________________________

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Do parents love the child?________________________________________________________________

Do they always encourage the child?_______________________________________________________

Are they always ready to help the child?____________________________________________________

Do they help the child in studies?__________________________________________________________

Do they allow the child to work and play according to his/her wishes?____________________________

Do they purchase the things of the childs liking/interest?______________________________________

Do they take the child along for entertainment?______________________________________________

Do they physically assault the child?________________________________________________________

Do they force the child to follow the general rules of home?____________________________________

Do they compare the child with his/her siblings?______________________________________________

About the Socio-Economic Status

Total income of the family________________________________________________________________

Sources of income______________________________________________________________________

Does the family has its own house?________________________________________________________

Is the income sufficient for all the family members?___________________________________________

Does the general needs of the family get fulfilled?____________________________________________

Does the family has good relations with the neighbors?________________________________________

Does the family avails all the facilities of entertainment?_______________________________________

Environment of the neighborhood family____________________________________________________

Occupations of the neighbors_____________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Social Status of the family________________________________________________________________

_____________________________________________________________________________________

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Educational Status

Age at the time of first admission in school__________________________________________________

Name of the school where the child has studied:

S No. Name of the School Date of admission Date of leaving Reasons for leaving

Result of the childs educational progress for the last 3 years

Exam Year Subjects and percentage of marks

Eng Pbi Hindi Sci Maths SST Phy.Ed GK Arts Moral

Sci

The subjects found interested by the child__________________________________________________

The subjects found boring by the child______________________________________________________

Activities in which the child actively participated______________________________________________

Name of the favorite sport_______________________________________________________________

Views of the important persons regarding the child

Views of the father_____________________________________________________________________

_____________________________________________________________________________________

Views of the mother____________________________________________________________________

_____________________________________________________________________________________

Views of the class incharge_______________________________________________________________

_____________________________________________________________________________________

Views of the other teachers______________________________________________________________

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_____________________________________________________________________________________

Views of the friends_____________________________________________________________________

_____________________________________________________________________________________

Views of the neighbors__________________________________________________________________

_____________________________________________________________________________________

Views of other related persons____________________________________________________________

_____________________________________________________________________________________

Views of guide on childs problem_________________________________________________________

_____________________________________________________________________________________

Main problem_________________________________________________________________________

_____________________________________________________________________________________

Possible reasons of the problem___________________________________________________________

_____________________________________________________________________________________

Guidance for solution of the problem_______________________________________________________

_____________________________________________________________________________________

Relation of the child with the teachers______________________________________________________

Relation of child with his/her classmates____________________________________________________

Status of the school_____________________________________________________________________

_____________________________________________________________________________________

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Details of the childs nature

Whether the child is:

Calm

Naughty

Sad

Aggressive

Always fearful

Emotional

Rude

Day dreamer

Teaser

ObedientJolly

Shy

Reserve

Loving

Hobbies of the child_____________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

What does he/she likes to read during his/her free time?_______________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Relations of the child with his/her friends___________________________________________________

Relations with siblings __________________________________________________________________

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Final diagnosis of the problem

Problem______________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Reasons diagnosed_____________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Guidance_____________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Results of the follow-up_________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Final Remarks (if any) ___________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Date:_________________ Signatures:_________________