CODE-UD in psychiatric education.

Morra & Ban

 

ENTRY FORM

 

PATIENT NUMBER:

RATER NUMBER:

DATE:DD-MM-YYYY

ASSESSMENT NUMBER:

 

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

I. Site of the assessment: 

II. Interviewer name

III. Patient`s name:

IV. Patient`s number:  

V. Assessment Number:

VI. Date of completion:

   (DD.MM.YYYY)

VII. Patient`s status:

    (Inpatient or outpatient)

VIII. What is your first language?

     Spanish         Portuguese      French             Italian              English   

     German        Slavic              Arabic             Chinese           Other

 

PATIENT NUMBER:

RATER NUMBER:

DATE:DD-MM-YYYY

ASSESSMENT NUMBER:

 

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

DEMOGRAPHICS

IX. Sex (Male, Female)

X. Race:

    White, Black, Native American, Hispanic, Asian, Other

XI. Date of birth:

     (DD.MM.YYYY)

XII. Place of birth:

      (City, Country)

XIII. Level of education?

     No formal education

     Elementary school/Grade school/ primary school 

     Completed/Partial/in progress    

     High school/Secondary school Completed/partial/in

     progress    

     Higher education (college, University)

     Completed/partial/in progress 

XIV. Last employment?

      Never employed, Unskilled laborer, Skilled

      laborer, Homemaker, Entrepreneur, Student,  

      Professional, Self-employed

XV. Employment status?

       Unemployed          Part-time employed                Fully employed          Retired          

XVI. Number of siblings:

       Twin:(mark only if the patient is a twin)

XVII. Marital status:

      Single          Married           Separated        Divorced         Widow   

      Cohabiting    N/A

XVIII. Age of first marriage:

XIX. Number of children:

       Biological:                  Adopted:

XX. Household composition: (mark all which apply)

      Patient         Spouse            Children          Siblings  

      Parents        Hospital          Retirement home        Other    

XXI. Number of people in household: