Clinical Data Sheet

Registration Number: ___________________ Date : __________________

 Diagnosis as per ICD 10 -

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 Onset –

Age in years –

Mode - Acute Abrupt Insidious

 No. of Episodes with type, if any –

 Total duration of illness years –

 Duration of present episode -

 Treatment History –

Medication –

Type –

Duration -

Psychotherapy –

Type –

Duration -

 Family history of mental illness–

Condition –

Relationship with patient – First degree

Second degree