Best Rehabilitation and Psychiatric Treatment in Bhubaneswar

ADARSH HOME

PSYCHIATRIC WELLNESS & REHABILITATION CENTRE

CASE HISTORY & ASSESSMENT BOOKLET

Patient / Guardian Intake and Professional Clinical Assessment

STRICTLY CONFIDENTIAL

Intake Summary

Patient Full Name:*

Case / UHID No.:

Date of Admission / Assessment:

Primary Guardian Name:

Primary Guardian Contact Number:

A. How to Use this Booklet

Purpose: This booklet helps the Adarsh Home clinical and counseling team understand the patient's background, current concerns, treatment history, family situation, safety needs, and rehabilitation goals. Please fill this out accurately.

Who should complete each part?

Part I - Patient / Guardian Intake: completed by the patient, guardian or admission staff.

Part II - Professional Clinical Assessment: completed only by the counsellor, psychologist or psychiatrist.

PART I - PATIENT / GUARDIAN INTAKE

1. ENQUIRY DETAILS

2. PATIENT INFORMATION

Date of Birth:*

Age:*

Gender:*

Patient Phone Number:

Current Address:*

Permanent Address:*

Languages Known:*

Religion (optional):

Community / Caste:

Education:*

Current Occupation:

Monthly Income (if applicable):

Blood Group (if known):

Marital Status:*

Single

Married

Separated

Divorced

Widowed

About the Patient

1. What is the patient's best quality?

2. What does the patient enjoy doing?

3. What are the patient's favourite activities, food, music, movies or sports?

4. What is the patient's biggest achievement?

5. What are the patient's future goals or dreams?

3. MAIN REASON FOR SEEKING HELP

What is the main problem for which help is being sought?*

When did the problem first start?

Approximate duration:

How did the problem begin?

What is the biggest concern for the family right now?

4. HISTORY OF THE PRESENT PROBLEM

1. What was the patient like before the problem started?

2. What was the first change noticed?

3. How has the problem changed over time?

Improved

Worsened

Remained the same

Comes and goes

Not sure

4. Are there situations that make the problem worse?

5. What helps the patient feel better?

Details of the event, if any:

Has the patient had a similar problem before?

Yes

Don't Know

If yes, describe the previous episode(s):

5. CURRENT MENTAL & EMOTIONAL HEALTH

General Functions

Area	Condition Option (Select one)
Sleep	Normal Less More Disturbed
Appetite	Normal Less More
Mood	Happy Sad Irritable Anxious Unstable Other
Energy	Normal Low Very High
Concentration	Good Fair Poor
Memory	Good Fair Poor

Specific Mental Symptoms

Item	Yes	No	Don't Know
Hears voices when nobody is speaking
Sees things that others cannot see
Believes someone is trying to harm or follow them
Has unusual or unrealistic beliefs
Talks excessively or behaves unusually
Talks or laughs to self
Shows severe fear or panic
Has frequent crying spells
Appears confused or disoriented

Details of any "Yes" answer:

6. SAFETY & RISK ASSESSMENT

Item	Yes	No	Don't Know
Talked about wanting to die or end life
Tried to harm self
Tried to harm another person
Became physically aggressive
Used a weapon or dangerous object
Broke things or damaged property
Ran away or went missing
Threatened family members or others
Refused food or water
Severely neglected personal care
Had dangerous or risky behaviour

Please describe any serious incident, including date and outcome:

Current urgency:

No immediate risk known

Needs prompt clinical review

Needs emergency medical / psychiatric attention

Not sure

7. PSYCHIATRIC TREATMENT HISTORY

Has the patient received psychiatric treatment before?

Yes

Don't Know

Doctor's Name:

Hospital / Clinic:

Diagnosis (if known):

Treatment duration:

Number of psychiatric admissions:

Last consultation date:

Has the patient been admitted to a psychiatric or rehab facility before?

Yes

What treatment was given?

Is the patient currently taking psychiatric medicines?

Yes

List current medicines and doses, if known:

Medicine use:

Takes regularly

Sometimes misses doses

Often refuses

Stopped completely

Family supervises medicines

Not known

If medicines were stopped or missed, why?

Any side effects or concerns about medicine?

8. GENERAL MEDICAL HISTORY

Medical Event	Yes	No	Details
Serious accident
Head injury
Seizure / fits
Major surgery
Serious illness
Loss of consciousness

Known allergies (medicine, food or other):

Current non-psychiatric medicines:

9. SUBSTANCE USE HISTORY

Substance	Never	Past	Current	Age Started	Frequency / Qty	Last Use
Alcohol
Tobacco / Cigarettes
Smokeless Tobacco / Gutkha
Cannabis / Ganja
Opioids / Heroin / Brown Sugar
Sleeping Pills / Sedatives
Inhalants
Other Drugs

What happens when the patient reduces or stops the substance?

Has the patient tried to stop before?

Yes

Previous de-addiction treatment and outcome:

Problems caused by substance use:

Family conflict

Financial loss

Job loss

Legal problem

Relationship problems

Health problems

Violence / aggression

Accident

Academic problems

10. FAMILY INFORMATION

Father & Mother Information

Father - Name:*

Father - Age:*

Father - Occupation:*

Father - Health Status:*

Mother - Name:*

Mother - Age:*

Mother - Occupation:*

Mother - Health Status:*

Siblings Details:

Sibling Name	Age	Occupation / Education	Relationship with Patient	Action

Other important family members or caregivers:

Family history of health concerns (mental or physical):

Mental illness

Depression

Suicide attempt

Suicide

Alcohol addiction

Drug addiction

Epilepsy

Other serious illness

None known

Who was affected and what was the problem?

11. CHILDHOOD & DEVELOPMENT

Where did the patient spend most of their childhood?

How was the patient's childhood? (Tick all that apply):

Generally happy

Difficult

Financially difficult

Family conflict

Neglect

Physical abuse

Emotional abuse

Sexual abuse

Frequent illness

Did the patient face any major problem during childhood?

Did the patient have developmental, learning or school difficulties?

Why did the patient stop education, if applicable?

12. EDUCATION, WORK & FINANCES

Highest qualification:

Year completed:

Favourite subjects:

Any special achievement:

Academic performance:

Poor

Average

Good

Excellent

Not applicable

Age when started working:

Previous jobs:

Reason for leaving previous jobs:

Has the patient lost a job because of mental illness or substance use?

Yes

Has the patient had long periods without work?

Yes

Details:

Financial impact of the condition:

Loss of income

Debt

Loss of property

Borrowing money

Family financial problems

No major impact

13. RELATIONSHIPS & MARRIAGE - Complete only if applicable

Name of spouse:

Age:

Duration of marriage:

Marriage type:

Relationship with spouse:

Major relationship problems, if any:

Any separation or divorce?

Yes

Any history of domestic violence?

Yes

Any children?

Yes

Relationship with children:

Has the patient experienced a major breakup or emotional loss?

Yes

Details:

14. BEHAVIOUR & SOCIAL LIFE

Relationship With Options

Relationship With	Good	Average	Poor	Not Applicable
Parents
Siblings
Spouse
Children
Friends
Neighbours
Colleagues / Employer

Social Behaviours

Item	Yes	No	Don't Know
Prefers to stay alone
Has difficulty making friends
Has frequent arguments
Becomes easily angry
Has difficulty controlling emotions
Faces social rejection or disrespect
Avoids family gatherings
Has conflicts with neighbours or outsiders

Details:

15. DAILY ROUTINE & LIFESTYLE

Daily Schedule

Morning:

Afternoon:

Evening:

Night:

Mobile use per day:

Social media use per day:

Online games per day:

Television / Internet per day:

Physical activity:

Regular exercise

Walking

Sports

Yoga

No regular activity

Hobbies and interests:

16. PERSONALITY BEFORE THE ILLNESS

What changes have been noticed in the patient’s personality?

17. IMPORTANT LIFE EVENTS & TRAUMA

Please explain any event that affected the patient emotionally:

18. LEGAL HISTORY

Legal Issue	Yes	No	Details
Police case
Criminal case
Civil case
Arrest
Drunk driving case
Accident while driving
Legal problem due to substance use
Legal problem due to aggression or violence

Additional details:

19. SPIRITUAL & RELIGIOUS LIFE

20. PATIENT STRENGTHS

What are the patient’s strongest qualities?

Who is the patient’s biggest emotional support?

What motivates the patient?

What does the patient want to achieve after treatment?

21. FAMILY EXPECTATIONS FROM TREATMENT

What is the family’s most important expectation from Adarsh Home?

22. PATIENT’S OWN GOALS

What does the patient want to change in their life?

What does the patient want to achieve after treatment?

What support does the patient expect from the family?

23. SERVICES REQUESTED

24. COMMUNICATION PREFERENCES

Communication / Service	Yes	No	Preferred Contact / Notes
WhatsApp updates
Telephone updates
Guardian counselling
Patient progress updates
Separate patient / guardian digital access

Preferred contact person:

Preferred calling time:

25. TREATMENT PREFERENCE

Preferred package / treatment type:

Budget Friendly

Standard

Premium

Not Decided

To be recommended by clinical team

Preferred treatment duration:

Short Term

Long Term

Not Decided

To be recommended by clinical team

Any financial, family, cultural or practical concern that may affect treatment?

PART II - PROFESSIONAL CLINICAL ASSESSMENT

For completion by authorised Adarsh Home clinical staff only.

26. INITIAL PROFESSIONAL ASSESSMENT - Staff use only

Assessment Date:

Assessor Name:

Designation:

Informant(s):

Reliability of information:

Good

Fair

Poor

Unable to assess

Primary concerns identified:

Major strengths of the patient:

Major family concerns:

Protective factors / support system:

27. MENTAL STATUS EXAMINATION - Staff use only

Domain	Clinical Findings
Appearance & grooming
Behaviour & psychomotor activity
Rapport & cooperation
Speech
Mood - subjective
Affect - objective
Thought form
Thought content
Perception
Orientation
Attention & concentration
Memory
Intelligence / abstraction
Insight
Judgement

28. CLINICAL RISK FORMULATION - Staff use only

Suicide / Self-harm Risk

Low

Moderate

High

Immediate / Emergency

Unable to assess

Evidence and current plan / intent / means:

Violence / Aggression Risk

Low

Moderate

High

Immediate / Emergency

Unable to assess

Evidence, triggers and access to weapons / dangerous objects:

Other Clinical Risks

Severe withdrawal

Absconding

Self-neglect

Medication refusal

Falls

Medical instability

Exploitation / abuse

Immediate safety measures and supervision required:

29. CLINICAL IMPRESSION & DIAGNOSIS - Staff use only

Provisional diagnosis:

Differential diagnosis:

ICD / DSM code (if used):

Severity:

Comorbid conditions:

Level of care recommended:

Clinical formulation / summary:

30. INDIVIDUALISED TREATMENT & REHABILITATION PLAN - Staff use only

Primary problems to be addressed:

Short-term goals:

Long-term goals:

Intervention	Plan / Frequency	Responsible Professional	Review Date
Psychiatric review / medication
Individual counselling
Family / guardian counselling
Psychological intervention
De-addiction intervention
Yoga / physical activity
Diet / nutrition
Occupational / vocational therapy
Psychoeducation
Social skills / community reintegration
Relapse prevention
Aftercare / follow-up

Recommended duration of treatment:

Discharge readiness criteria:

Follow-up plan:

31. REVIEW & PROGRESS SUMMARY - Use for periodic review

Review Date:

Review Number:

Reviewed By:

Current Risk Level:

Progress since last review:

Current challenges:

Changes in treatment plan:

Family feedback:

Next review date and action points:

32. DOCUMENT CHECKLIST

Documents pending:

33. CONSENT & DECLARATION

I / We declare that the information provided in this booklet is true to the best of our knowledge. I / We understand that complete and accurate information helps the clinical team plan safer and more effective treatment. I / We consent to assessment, treatment planning and communication with the authorised guardian / contact person, subject to applicable professional and legal requirements.

Patient Name:

Guardian Name:

Relationship to Patient:

Date:

Signatures / Verifications

Patient Signature / Thumb Impression Name:

Guardian Signature Name:

Counsellor / Assessor Signature Name:

Psychiatrist Signature Name:

Counsellor Signature Date & Time:

Psychiatrist Signature Date & Time:

Clinical Emergency Note: Any immediate risk of suicide, violence, severe withdrawal, loss of consciousness, seizure, breathing difficulty or other medical emergency requires urgent clinical intervention and should not wait for completion of this form.