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(51) Retardation
(52) Social impairment
(53) Disorientation
(54) Hallucination
(55) Fall
(56) Breathlessness
(57) Suicidal ideas
(58) Fatigue
(59) Others (specify)
(60-61) Total score
SECTION III
CLINICAL VARIABLES - CASE SHEET
         
Personal Particulars :        
Name : Age :    Sex :  
Address :        
GRH OP No. I.P. No.      
Psych. OP No. I.P. No.      
POMR No.        
(1-3) Job Number      
(4-5) Card Design      
(6-7) Card Number      
(8-9) Sub-centre      
(10-11) Village      
(12-14) Serial No.      
(15) Reasons for consultation (Patient's complaints) Duration      

Key : Number of complaints

       
1.
2.
3.
4.
5.
6.
       
(16) How referred      
Visit by MPHW
Visit by Project S. W.
Visit by Project R.O.
Referred by: PHC MO
1
2
3
4
     
(17) Onset      
Acute
Subacute
Insidious
1
2
3
     
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