N˚

Question

Answer

Date:

………………….

A

Socio-demographic information

Q1

Age

………………….

Q2

Sex

-Male

-Female

Q3

Ethnic group

………………….

Q4

Nationality

………………….

Q5

Religion

-Christian

-Muslim

-Animist

Q6

Marital status:

-Single

-Married

-Cohabiting

-Divorced

-Other

Q7

Family type:

-Monogamous

-Single-parent

-Polygamous

Q8

Occupational status

-Pupil/Student

-Trader

-Official

-Worker

-Unemployed

-Others

Monthly income (USD):

………………….

B

Reason for consultation

Q9

Why did you come for a consultation today?

………………….

C

Past history

Q10

How long have you been treated in this department?

:…(days/month/year)

Q11

Have you had any psychiatric treatment in the past?

-Yes

-No

D

Universal risk factors

Tick the box(es) that apply to you.

Q12

Are you a victim of discrimination, violence or abuse?

-Yes

-No

Q13

Do you feel isolated and/or unsupported?

-Yes

-No

Q14

Are you in conflict with the people around you?

-Yes

-No