k|ZgfanL e/]sf] ldltM ===========÷========÷===========

K6+

olb pknAw 5 eg] n]jn 6fF:g'xf];\gfd, y/c? gfdePdf
hGd ldlt
lnË7]ufgf

Provider:______________
Provider ID

pQ/bftfsf] ;Í]tf+sk'?if

JolQm g+=dlxnf

tnsf k|Zgx?df tkfO{n] uPsf] Ps dlxgf ÷#) lbgdf ug{'ePsf cg'ejx?÷cj:yfsfaf/]df ;f]lwPsf 5g\ . tn lbO{Psf cj:yf tkfO+{n] sltk6s h:tf] cg'ej ug{'ePsf]lyof] tkfO+{sf cg'ej ;+u ;a}eGbf al9 ldNg] c+sdf uf]nf] lrGx nufP/ hgfpg'xf];\.
k|Zg g+ != uPsf] #) lbgdf,
tkfO{+ nueu sltk6sh:tf] Ò;w}w]/}h;f]slxn]sflx+lj/n}÷ Psbd
sd dfqslxNo} klg ePg

s= cflQg], sxflng], 8/fpg]] jÞf d'6'
9's9's x'g] x'g'ePsf] lyof]<!

@#$%v= eljiodf s]xL klg ug{ ;lSbgeg]/ x/]; vfg'ePsf] lyof]<!

@

#

$%

u= 56k6L x'g], Ps 7fpFdf l:y/ eP/
a:g g;Sg] jÞf sxfF hfpF s] u?F h:tf]
x'g'ePsf]] lyof]<!

@

#

$%

3= tkfO+{sf] dgdf ePsf] lbSbfl/kg,pbfl;kg jÞf lvGgtfn] ubf{ s'g}klg
s'/fn] s]xL u/]klg v'zL x'gg;Sg]
x'g'ePsf] lyof]<!

@

#

$%

ª= h] sfd ubf{klg Psbd} hfFu/
gnflusg hah{:tL ug{ k/]sf] h:tf]nfu]sf] lyof]<!

@#$%r= cfkm"nfO{ sfd gnfUg] a]sf/sf]
dfG5] h:tf] 7fGg'ePsf] lyof]<!

@#$%s[kof kfgf kN6fpg'xf];\ .

k|Zg g+ @= cufl8sf ^ j6f k|Zgx? ljut #) lbgsf] cjlwdf tkfO{n] ug{' ePsf cg'ejx?sf]af/]df ;f]lwPsf] lyof] . tL ;a} cg'ejx?nfO{ ljrf/ u/]/ eGg kbf{ uPsf] #) lbgdf tkfO{+sf]
nflu tL cg'ejx? c? ;fdfGo ;dosf] eGbf a9L, c? ;fdfGo ;dosf] hlt g}, cyjf
c? ;fdfGo ;dosf] eGbf sd k6s ePsf lyP< -olb tkfO{+nfO{ tL s'g}klg cg'ejx? slxNo}
klg ePsf lyPgg\ eg], pQ/ $ df uf]nf] lrGx nufpg'xf];\ .
;fdfGo eGbf a9LPsbd} a9L s]xL a9L@!

;fdfGo hlt g}yf]/} a9L#$;fdfGo eGbf sdyf]/} sd s]xL sd Psbd} sd%^&casf s]xL k|Zgx? uPsf] #) lbgdf tkfO+{n] ug{' ePsf tL cg'ejx?÷tkfO{+sf] cj:yfn]
tkfO+{nfO{ s:tf] c;/ u/]sf] x'g;S5 eGg] ljifodf 5g\. -olb cufl8sf ;a} ^ j6f k|Zgx?dfslxNo} klg ePg eGg] pQ/ nufpg'ePsf] 5 eg] tkfO+{n] tnsf k|Zgx?sf] pQ/ lbg'kb}{g,tkfO{+sf] ;xof]u / ;dosf] nflu w]/} w]/} wGojfb .
k|Zg g+ #= uPsf] #) lbgdf, tL cg'ejx?÷cj:yf sf sf/0fn] ubf{ tkfO+{n] slt lbg cfˆgf] sfd
jf ;fdfGo sfdsfh k6Ss} -slQ klg_ ug{ ;Sg'ePg<============ -lbg_k|Zg g+ $= k6Ss} -slQ klg_ sfd ug{ g;Sg' ePsf] lbgnfO{ gugLsg ÷ lx;fa gubf{, uPsf]#) lbgdf slt lbg tkfO+{n] dfyL eGg' ePsf cg'ejx?÷ cj:yfsf sf/0fn]
ubf{ tkfO+{n] ;fdfGotof ug]{ u/]sf] sfd eGbf cfwf jÞf Tof] eGbf sd dfq sfd ug{ ;Sg'ePsf]lyof]<===========-lbg_
k|Zg g+ %= uPsf] #) lbgdf, tkfO+{n] ug'{ ePsf tL cg'ejx?÷ cj:yf sf sf/0fn]
ubf{ tkfO+{ sltk6s lrlsT;s jf :jf:yosdL{ ;+u hFrfpg hfg'eof]<============-k6s_;w}k|Zg g+ ^= uPsf] #) lbgdf, tkfO{+n]dfly pNn]v ug{'ePsf cg'ejx?
cyjf cj:yfx? -h:t}M cflQg],!
56k6L x'g] OToflb _ sf k|d'v sf/0f
sltk6s c? zfl/l/s :jf:Yo ;d:ofx?
ePsf lyP<w]/}h;f]slxn]sflx+lj/n}÷Psbd
sd dfqslxNo} klg ePgg\@#$%of] k|ZgfjnL eg'{ePsf]df w]/} w]/} wGojfb 5 .

© Ronald C. Kessler, PhD. 2013
All rights reserved. Based on the Composite International Diagnostic Interview © 2001 Ronald C. Kessler,
PhD. All rights reserved. Used with permission. Requests for permission to reproduce or translate should
be addressed to Professor Ronald Kessler, PhD, Department of Health Care Policy, Harvard Medical
School, (email: ronkadm@hcp.med.harvard.edu).

Acknowledgements
Translation of this document was performed on behalf of the Composite International Diagnostic
Interview Advisory Committee by Bimala Panthee and Norito Kawakami, MD, University of Tokyo,Tokyo, Japan.