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: