CODE-UD in psychiatric education.

Morra & Ban

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: