Please indicate the degree of psychological disturbance in your patient today by circling an appropriate option: |
Normal/stable person with or without physical illness | | 1 |
Person with sub-clinical emotional or behavioural disturbance | | 2 |
Person with mild psychological disturbance | | 3 |
Person with moderate psychological disturbance | | 4 |
Person with severe psychological disturbance requiring referral | | 5 |
|
Do you regards this person as having: |
Chronic psychological problems? | Yes | No |
Significant mental health problems within the last year? | Yes | No |
|
Diagnosis for today's consultation: ____________________________________________ |
Did you: |
Issue a script? (If so, indicate prescription: ________________________) | Yes | No |
Make a follow-up appointment? | | |
Refer this patient to a specialist service? (If so, which ______________) | Yes | No |
|
Did you discuss any psychological issue in today's consultation? | Yes | No |