1. HoNOS65+ Score Sheet Place sticker here HoNOS 2009/10 Patient Forename
Patient Surname
Date of Birth Gender
NHS number
Postcode
Ward / Team Base Name
Service Type (please circle)
Inpatients/ CMHT/ CRHT/ AOT/ EIP/ Day Services
Consultant Name
Rater 1 Name (& Profession)
Rater 2 Name (& Profession)
Place sticker here
Key
NB. Rate preceding fortnight or “condition at discharge” for acute services.
0 = No problem, 1 = minor problem-requiring no action, 2 = Mild problem but definitely present, 3 = Moderate, 4 = Severe,
U = Not known (avoid using if possible)
Sheets with more than 2 unknown items will be returned
Last date of rated period here dd/mm/yyyy
Rating Setting ID 1) Hospital Admission, 2) Hospital Review 3) Hospital Discharge 4)Community Initial Assessment 5) Community Review 6) Community Discharge 7) Outpatients Initial Assessment 8) Outpatients Review 9) Outpatients Discharge 10) Crisis team admission 11) Crisis team discharge 12) Liaison Assessment 13) other (specify)
1) Overactive, aggressive, disruptive or agitated behaviour
0-4
2) Non-accidental self-injury
3) Problem drinking or drug taking
4) Cognitive Problems
5) Physical illness or disability problems
6) Problems with hallucinations and delusions
7) Problems with depressed mood
8) Other mental or behavioural problems (0-4) Rate 0 for no problem
Specify single most severe disorder A – J Not rated elsewhere
A) phobic, B) anxiety, C) obsessive-compulsive, D) Stress, E) dissociative, F) somatoform, G) eating, H) sleep, I) sexual, J) other (specify)
A-J
9) Problems with relationships
10) Problems with activities of daily living
11) Problems with living conditions
12) Problems with occupation and activities
Total
Primary Diagnosis 1) Dementia, 2) Delirium, 3) Substance Misuse - Drug 4) Substance Misuse - Alcohol 5) Schizophrenia/ Schizoaffective Disorder 6) Bipolar 7) Depression 8) Eating Disorders 9) Borderline Personality Disorder 10) MCI (mild cognitive impairment) 11) Other (specify) e.g. Anxiety
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