Schizophrenia Performa
UHID
OPD No
IPD No
Casulty No
Name

Mobile
Adhaar No
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Name
Age YY
Age MM
Age DD
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Notes

  • ICDCode DiseaseName ICDName Since Unit From Birth
Do other family know and understand about symptoms of Schizophrenia

What has been done to address the psychotic symptoms? With what results?
Specific To the Caregiver

In what ways has the psychotic symptoms affected your everyday life?

  • Question Result Remarks
    Is there a history of schizophenia illness in the family (including the caregiver and receipient)?
    Is there any history of absconding in the family?
    Is there any history of suicide in the family?
    Is there a history of psychological and/or phychitric treatments in the family?
    Is there a history of psychological/emotional/sexual abuse in the family?
    Who are in involved in the decision making about the care recipient and in what capacity?
    what do you do to take care of yourself?
    what would you want to accomplish during our work together?
  • PHARMACOLOGICAL
    • Question Result Remarks Question Level
      ACUTE MANAGEMENT
      MAINTENANCE PLAN
  • NON PHARMACOLOGICAL
    • Question Result Remarks Question Level
      FAMILY COUSELING
      SOCIAL SKILLS TRAINING
      COGNITIVE RETRAINING
      COGNITIVE BEHAVIOR THE
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Imaging List
  • Question Result Remarks
    Do you feel fearful or suspicious
    do you ever feel people are talking about you or discussing about you
    Do you ever hear voices which are not heard by others
    Do peoples discuss about you behind your back
    Do you feel like being alone and not motivated to do any work
    Do you feel that you are being controlled by some external agency
    Do you feel your actions feeling or emotions are controlled by some external agency
    Do you feel your throughts are being withdrawn by external agency being known to people without your saying
    Do you feel things unseen to others, feel odd sensations within the body or smell odd smells?
    Have there been periods of mutism ,standing or sitting in odd postures for long time?
  • Question Result Remarks
    PSYCHITRY
    MEDICAL
  • Question Result Remarks
    PSYCHITRY
    MEDICAL
  • Question Result Remarks
    PSYCHITRY
    MEDICAL
  • Question Result Remarks
    BIRTH AND EARLY DEVELOPMENT
    EDUCATION
    OCCUPATION
    MARITAL HISTORY
  • Question Result Remarks
    GENERAL EXAMINATION
    GASTROINTESTINAL SYSTEM
    RESPIRATORY SYSTEM
    MUSCULOSKELETEL SYSTEM
    CARDIOVASCULAR
    NERVOUS SYSTEM
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