CODE-UD in psychiatric education.
Morra & Ban
THIS FORM NEEDS TO BE COMPLETED PRIOR TO ANY CODE-UD PROCEDURE
IX. Sex (Male, Female)
White, Black, Native American, Hispanic, Asian, Other
XI. Date of birth:
XII. Place of birth:
XIII. Level of education?
No formal education
Elementary school/Grade school/ primary school
High school/Secondary school Completed/partial/in
Higher education (college, University)
XIV. Last employment?
Never employed, Unskilled laborer, Skilled
Laborer, Homemaker, Entrepreneur, Student,
XV. Employment status?
Unemployed Part-time employed Fully employed
XVI. Number of siblings:
Twin:(mark only if the patient is a twin)
XVII. Marital status:
Single Married Separated Divorced Widow
XVIII. Age of first marriage:
XIX. Number of children:
XX. Household composition: (mark all which apply)
Patient Spouse Children Siblings
Parents Hospital Retirement home Other
XXI. Number of people in household: