Medical History
Investigator
text
Date of Medical History Taking
date
Actual Medical History
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Referral
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Comment
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Social Anamnesis
The question relates to the main situation in the last year. If one of the patient's occupations exceeds 75 percent, only one option is indicated. If none of the patient's occupations exceeds 75 percent, two (2) alternatives may be specified. Several responses are possible.
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Determine the number of affective episodes.
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
boolean
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
float
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
boolean
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
float
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
boolean
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
float
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
boolean
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
float
Summarize the weeks for all verified affective episodes during the year. Give an approximate value in case of doubt.
integer
Complete remission = no significant signs or symptoms of bipolar affective episodes. Without complete remission between relapses = not completely symptom free but with symptoms of bipolar affective episodes that do not fully meet the criteria. One answer can be given.
text
Self-Injurious Behavior
Self-harmful action refers to the intentionally inflicting bodily injury without suicidal insight (eg by biting, headache, scratching, tearing, cutting, drowning of the body, ingestion of inedible substances and fluids, taking out of medication beyond ordination, dose poisoning with apparently non-lethal dosage or by burning).
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One Answer only.
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Suicide attempts are meant to be life-threatening or apparently life-threatening behavior, in order to put their lives at stake or to express such an intention but do not lead to death (eg severe tablet poisoning, drowning, shooting, hanging / tightening).
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One Answer only.
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Treatment History
Treatment for bipolar disorder
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- Patient education for bipolar disorder (educational initiative that follows a predefined education program comprising a number of training courses where the content aims to provide increased knowledge about disease and treatment, strategies to handle everyday symptoms and opportunity for exchange of experience) - Systematic psychological treatment (eg psychodynamic, dialectic-behavioral, interpersonal, cognitive or cognitive behavioral therapeutic treatment) - Neuropsychological investigation (investigation with standardized tests that measure cognitive functions as attention, memory function, concentration ability, learning ability)
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Treatment for bipolar disorder: Time of Treatment
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- Patient education for bipolar disorder (educational initiative that follows a predefined education program comprising a number of training courses where the content aims to provide increased knowledge about disease and treatment, strategies to handle everyday symptoms and opportunity for exchange of experience) - Systematic psychological treatment (eg psychodynamic, dialectic-behavioral, interpersonal, cognitive or cognitive behavioral therapeutic treatment) - Neuropsychological investigation (investigation with standardized tests that measure cognitive functions as attention, memory function, concentration ability, learning ability)
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Regardless of the number of times in a treatment series. ECT = Electroconvulsive Treatment (KVÅ codes DA006, DA024 and DA025)
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Electroconvulsive Therapy: Number
float
Estimate the treatment effect according to CGI-I. Compared with the patient's condition before treatment, how much has he / she changed? Circle the appropriate option.
integer
Electroconvulsive Therapy: Last Treatment
text
Ongoing Pharmacotherapy
Refers to ongoing drug treatment and includes Karbamazepine, Clonazepam, Lamotrigine, Lithium, Oxcarbazepine, Quetiapine, Topiramate, Valproate, and other mood stabilizing drugs. One answer can be given.
text
Several answers are possible.
text
Lithium Therapy: Start Date
date
(decimal with one decimal place)
float
Renal Function
text
Creatinine
integer
Cystatin C
float
Iohexol Clearance
integer
Renal Function Test
text
Refers to ongoing drug treatment including Alimemazine, Aripiprazole, Dixyrazine, Flufenazine, Flupentixol, Haloperidol, Chlorpromazine, Kloprotixen, Klozapine, Levomepromazine, Melperon, Olanzapine, Paliperidone, Perfenazine, Pimozide, Quetiapine, Risperidone, Sertindole, Sulpiride, Tioridazine, Ziprasidone, Zuclopentixol, Ev other antipsychotic drug.
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Examples of typical antipsychotic drugs: Dixyrazine, Flufenazine, Haloperidol, Chlorpromazine, Chlorprotixen, Levomepromazine, Perfenazine, Tioridazine. Examples of atypical antipsychotic drugs: Aripiprazole, Klozapine, Risperidone, Olanzapine, Quetiapine, Paliperidone, Sertindole, Ziprasidone. Several response options can be specified
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Antidepressive Agents
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Antidepressive Agents: Specification
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Refers to ongoing drug treatment and includes Atomoxetine, central stimulant, and any other drug against ADHD. By central stimulant medicine is meant e.g. methylphenidate, dexamethetamine, modafinil, but not atomoxetine. One answer can be given.
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Several answers are possible.
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Refers to ongoing drug treatment and includes Alprazolam, Buspiron, Diazepam, Flunitrazepam, Hydroxizin, Lorazepam, Klometiazole, Nitrazepam, Oxazepam, Pregabalin, Prometazin, Propiomazine, Propranolol, Triazolam, Valeriana, Zaleplon, Zolpidem, Zopiclone, and other benzodiazepine-like drugs.
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Levothyroxine
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Adverse reaction to drug
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Adverse reaction to drug: Preparation
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Adverse reaction to drug: Specification
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Somatic Factors
Includes diagnosed states, suspected conditions investigated (even if diagnosis is not yet established) as well as complicating circumstances.
text
Several answers are possible.
text
Somatic Factors: Others
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HbA1c
boolean
HbA1c = "long-term measure" of glucose levels (blood sugar). The HbA1c level reflects the average P-Glucose level below the last 6-8 weeks before sampling. The answer is given in integers.
integer
Systolic Blood Pressure
boolean
Systolic blood pressure, upper pressure (mm Hg) registered in sitting after at least two minutes rest (recommendation).
integer
Diastolic Blood Pressure
boolean
Diastolic blood pressure, lower pressure (mm Hg) recorded in sitting after at least two minutes rest (recommendation).
integer
Body Weight
boolean
Weight = kg, without outerwear, jacket and shoes. (Decimal by one decimal place)
float
Body Height
boolean
Length = cm, without shoes.
integer
Substance Use Disorders
Nicotine
text
By nicotine replacement, nicotine patches and nicotine gum. Several responses can be specified.
text
AUDIT C are the first three questions of the AUDIT. Score: 0-12 Risk Use ≥ 4 points (man), ≥ 3 points (female). A glass is defined as one of the following: 45 cl beer, 33 cl beer, 15 cl of wine, fortified wine Cl 8, 4 cl liquor.
integer
AUDIT C are the first three questions of the AUDIT. Score: 0-12 Risk Use ≥ 4 points (man), ≥ 3 points (female). A glass is defined as one of the following: 45 cl beer, 33 cl beer, 15 cl of wine, fortified wine Cl 8, 4 cl liquor.
integer
AUDIT C are the first three questions of the AUDIT. Score: 0-12 Risk Use ≥ 4 points (man), ≥ 3 points (female). A glass is defined as one of the following: 45 cl beer, 33 cl beer, 15 cl of wine, fortified wine Cl 8, 4 cl liquor.
integer
(0 - 12 points)
integer
Psychiatric comorbidity - Based on clinical interview, MINI interview or other instruments:
Psychiatric comorbidity
text
Several answers are possible.
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One answer only.
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Substance abuse refers to malicious use and / or addiction. Combination (F19.1 / F19.2) is applied when it is known that two or more psychoactive substances have been used but when it is impossible to determine which one contributed most to the disturbance. The category should be used as well when one or more of the substances are unknown or can not be accurately identified. Several answers are possible.
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Global Assessment of Functioning
The question is answered if the patient is 21 years of age or older. The GAF scale is a global functional assessment scale for estimating psychological, social and professional functionalities. Instruction: Note that the value 0 (insufficient information) should always be stated when it is estimated that there is no basis for a clinically relevant assessment on the part scale. This may be the case when the symptom source makes the assessment of the level of functioning too uncertain or when the assessment is made in circumstances that are not representative or adequate as a basis for a functional assessment, e.g. when the patient is in closed care. (0 - 100)
integer
The question is answered if the patient is 21 years of age or older. The GAF scale is a global function estimation scale for estimating psychological, social and professional functioning. Instruction: Note that the value 0 (insufficient information) should always be is stated when it is estimated that no clinical data can be obtained relevant estimation on the part scale. This can for example be the case when it is difficult to communicate with the patient that the symptom source can not clarified. (0 - 100)
integer
(The question is answered if the patient is 20 years and younger) One answer only.
text
Estimate the person's most impaired overall functional level during the specified time period by selecting the lowest level describing his / her functioning on a hypothetical continuum of health / illness. Also use intermediate levels (eg 35, 58, 62). The value "0" = insufficient information to be able to tax. C-GAS = Children's Global Assessment Scale. (0 - 100)
integer
(0 - 100)
integer
(0 - 100)
integer
CGI-S (Clinical Global Impression - Severity, Overall Clinical Impression of Disease Severity) * * Mandatory
One answer only.
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One answer only.
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Clinical Global Impression
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