
Last name:
First name:
Date of Birth (YYYY-MM-DD):
Age:
Sex: M|F|D
Gender: M|F|D
Weight:
Initial Stimulation Heuristics: Age | Titration | Other
@IF (Initial Stimulation Heuristics = Other)@ Initial Stimulation Heuristics Other:

Diagnosis manual used: ICD-10 | ICD-11 | DSM-5
@IF (Diagnosis manual used = ICD-10)@ Diagnosis (ICD-10): F33.1 | F33.2 | F33.3 | F20.0 | F20.1 | F20.2 | F20.3 | F31.1 | F31.2 | F31.3 | F31.4 | F31.5 | F31.6 | F32.1 | F32.2 | F32.3 | Other (please specify here)
@IF (Diagnosis manual used = ICD-10)@ Diagnosis (ICD-11): N/A
@IF (Diagnosis manual used = ICD-10)@ Diagnosis (DSM-5): N/A
@IF (Diagnosis manual used = ICD-11)@ Diagnosis (ICD-10): NA 
@IF (Diagnosis manual used = ICD-11)@ Diagnosis (ICD-11): 6A70.0 | 6A70.1 | 6A70.2 | 6A70.3 | 6A70.4 | 6A71.0 | 6A71.1 | 6A71.2 | 6A71.3 | 6A71.4 | 6A20.0 | 6A20.1 | 6A20.2 | 6A60.0 | 6A60.1 | 6A60.2 | 6A60.3 | 6A60.4 | 6A60.5 | 6A60.6 | 6A60.7 | 6A60.9 | Other (please specify here)
@IF (Diagnosis manual used = ICD-11)@ Diagnosis (DSM-5): N/A
@IF (Diagnosis manual used = DSM-5)@ Diagnosis (ICD-10): N/A
@IF (Diagnosis manual used = DSM-5)@ Diagnosis (ICD-11): N/A
@IF (Diagnosis manual used = DSM-5)@ Diagnosis (DSM-5): 296.32 | 296.33 | 296.34 | 295.90 | 295.70 | 296.42 | 296.43 | 296.44 | 296.52 | 296.53 | 296.64| 293.89 | 293.89 | 293.89 | Other (please specify here)

PATIENT ECT SERIES NUMBER: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15
@IF (PATIENT ECT SERIES NUMBER = 1)@ Year of first ECT: ${YEAR}
@EVAL{NUMVAL("PATIENT ECT SERIES NUMBER") != 1}@ Year of first ECT: 
