CODE-UD in psychiatric education.

Morra & Ban

DIAGNOSTIC FORM

PATIENT NUMBER:

RATER NUMBER:

DATE:DD-MM-YYYY

ASSESSMENT NUMBER:

THIS FORM NEEDS TO BE COMPLETED PRIOR TO ANY CODE-UD PROCEDURE

I. REFERED BY:________________(FIRST NAME, INITIAL, SURNAME)

   Self-referred

   Family/friend

   General practicionist

   Psychiatrist

   Other specialist  

   Resident

   Police

   General hospital

   Psychiatric hospital

   Retirement house

   Other_______________________________

II. TENTATIVE DIAGNOSIS

ICD 10 (Based on structured interview)

ICD 10 (Clinical Diagnosis)

DSM IV (Based on structured interview)

DSM IV (Clinical Diagnosis)

OTHER: _______________________________