Screening Form For Patients Over 10

Screening forms. PLEASE NOTE THAT APPOINTMENTS MAY NEED TO BE RESCHEDULED WITHOUT NOTICE DUE TO EMERGENCY SITUATIONS.

Screening Forms and additional information for all patients over 10
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
DateTime *
Height *
Weight *
Females: Last Menstrual Period

Month Day Year
Date
Allergies to Medications: *
Name of Therapist *
Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems? *

Not at all-0

Several Days-1

More than half the days-2

Nearly every day-3

1. Little interest or pleasure in doing things

2. Feeling down, depressed or hopeless

3. Trouble falling or staying asleep, sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down

7. Trouble concentrating on things, such as reading the newspaper or watching television

8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figety or restless that you have been moving around a lot more than usual

9. Thoughts that you would be better off dead, or of hurting yourself

Calculation
If you check off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all Somewhat difficult Very difficult Extremely difficult

Screening forms. PLEASE NOTE THAT APPOINTMENTS MAY NEED TO BE RESCHEDULED WITHOUT NOTICE DUE TO EMERGENCY SITUATIONS.