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					                                    Scottish Schizophrenia Outcomes Study Data Sheet
KEYWORKER DETAILS
                                                                                                                                FOR OFFICE USE ONLY
Surname:              Centre Number: 
                                                                                                                                 
Forename:             Date Form Completed:
                       /  / 
                                                                                                                                  
Location / Base
                                                                                                                      2
                                   Data Collection Phase
PARTICIPANT DETAILS

Surname                                                    Employment status
                                                                      Tick more than one box if required
                                                                                                                        Main Carer
                                                                                                                         No-one
                                                                       Full-time employment                             Partner
Forename:                                                                                                     Parent
                                                                       Part-time employment
                                                                       Unemployed                                       Daughter/ Son
Date of Birth:        /  /                                                                                       Friend
                                                                       Full-time education
                                                                       Part-time education                              Sibling
Gender:               Male         Female                                                                              Nursing staff
                                                                       Voluntary
                                                                       Sheltered / Supported                            Local authority staff
Postcode:               (1st half only)
                                                                                                                         Voluntary staff
                                                                       Sickness benefit
Currently registered with a GP:                Yes     No            DLA                                              Other: ____________________
                                                                       Retired                                         Lives with main carer?
Current ICD 10 Diagnosis: F                                        Other: _____________________                     Yes     No        N/A
(If ICD10 not known, enter F20)
                                                                                                                        Lives alone?         Yes    No
MEDICAL INFORMATION
                                                                                                           Medication
Within the last year, has the participant:                      Dual diagnosis:                            Regular Antipsychotic        Currently   Within the
                                                                (Tick more than one box if required)                                                last Year
                                  Yes         No        Not      None                                     Depot                                   
                                                      known
Been subject to detention?                                    Drugs                                    Typical (Oral)                          
                                                                 Learning Disability                      Atypical (Oral)                         
Been imprisoned?                                              Alcohol                                  Atypical (Depot)                        
                                                                 Other: _________________
Been on Care Programming?                                                                               Subject to Clozapine monitoring?  Yes
                                                                No formal diagnosis, but                                                             No
Attempted suicide?                                           known to misuse: (Tick more
                                                                than one box if required)                  PRN Antipsychotic
Self harmed?                                                  Drugs                                    Typical                                 
                                                                 Alcohol                                  Atypical                                
Number of psychiatric hospital                                  Current legal status:
                                                                                                           Anticholinergic                         
admissions in the last year:      ______                         Informal                                 Mood stabiliser                         
                                                                 Criminal Procedures Act                  Anxiolytic                              
                                                                 M.H.A                                    Antidepressant                          
                                                                 Guardianship
INTERVENTIONS / SERVICES DURING THE LAST YEAR
Tick all services that the participant has had contact with (or been offered) in the last year, and          Currently Living
all professions who have had contact with the participant, including your own profession.
                                                                                                                Own Home (includes tenancy)
 E.C.T.                                                Education programme
                                                                                                                Supported / Staffed accommodation
 Cognitive Behavioural Therapy                         Housing services
                                                                                                                Group Home – not staffed
 Other Psychological Interventions                     Social Support Package (includes Home Help)
                                                                                                                Acute Ward
 Family Intervention                                   Voluntary Services (SAMH, NSF, Penumb. etc)
                                                                                                                Medium Stay / Rehab Ward
 Alcohol problem services                              Social Work
                                                                                                                Long Stay Ward N.H.S
 Drug problem services                                 Support Worker
                                                                                                                N.H.S. Partnership Ward
 Forensic services                            Physiotherapy
                                                                                                                Nursing / Residential Home
 Rehab services                                         Occupational Therapy
                                                                                                                Homeless Hostel
 Inpatient services                           Psychiatry
                                                                                                                Other Hostel
 Outpatient services                                    Psychology
                                                                                                                Prison
 Day centre/hospital/resource centre                    Nursing, including CPN
                                                                                                                Forensic Unit

________________________________________________________________________________________________________
                                                        Scottish Schizophrenia Outcomes Study,
                              Research & Development, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow, G12 0XH
                                                 Tel: 0141 211 3582 www.schizophrenia-outcomes.org
 Other: please state: ________________    _______________      _________________                No Fixed Abode
                                                                                                 Other: ______________________

     PLEASE REMEMBER TO FILL IN THE OUTCOME MEASURE SCORES ON THE BACK OF THIS FORM.
                      HoNOS Score                                                                 Avon Score

Overactive, aggressive, disruptive or agitated behaviour                   Physical

Non-accidental self injury                                                  Food
Problem drinking or drug taking                                             Shelter / Accommodation
Cognitive problems                                                          Physical Health
Physical illness or disability problems                                     Self Care
Problems with hallucinations & delusions                                    ill Effects Of Treatment
Problems with depressed mood                                               Social

Other mental & behavioural problems
                                                                             Social Support
(specify A,B,C,D,E,F,G,H,I OR J)                                           Discrimination
                                                                             Daily Routine
Problems with relationships                                                 Community Involvement
Problems with the activities of daily living                               Behaviour                             Only Record Bad Day
Problems with living conditions                                             Sleep Disturbance
Problems with occupation & activities                                       Risk To Self
Total Score                                                                    Substance Misuse
                                                                             Alcohol
                                                                             Drugs
                                                                             Suicide
                                                                             Anger

Setting where rated: (enter one number only)                               Access
                                                                               Transport
                                                                                                                  Only Record Bad Day
    1    ACUTE (IN-PATIENT)
    2    LONG STAY (INCLUDING FORENSIC SERVICE)                              Availability
    3
    4
         DAY HOSPITAL
         DAY CENTRE                                                          Physical Access
    5    OUT-PATIENT DEPARTMENT
    6    OWN HOME                                                                Information
    7
    8
         CMHT/RESOURCE CENTRE
         REHABILITATION SERVICE
                                                                             Availability
    9    OTHER:__________________________                                    Understanding
                                                                             Communication
                                                                             Income
                                                                             Managing Money
                                                                            Mental Health                         Only Record Bad Day
                                                                             Mood Swings
                                                                             Depression
                                                                             Unusual Thoughts & Experiences
                                                                             Anxiety Or Fear
                                                                             Obsessive thinking / Compulsive Activities
                                                                             Problems with Forgetting & Understanding

________________________________________________________________________________________________________
                                                   Scottish Schizophrenia Outcomes Study,
                         Research & Development, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow, G12 0XH
                                            Tel: 0141 211 3582 www.schizophrenia-outcomes.org
                  On completion, please send in to the SSOS Office




________________________________________________________________________________________________________
                                             Scottish Schizophrenia Outcomes Study,
                   Research & Development, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow, G12 0XH
                                      Tel: 0141 211 3582 www.schizophrenia-outcomes.org

				
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