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
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Generalized Anxiety Disorder (GAD-7) scale
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
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might
happen
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
How many hours are you sleeping per night?
*
How is your appetite?
*
Are you exercising regularly?
*
Are you experiencing medication side effects?
*
Describe your mood
*
Are your symptoms affecting home or work life? If so, please describe.
Are you experiencing any of the following symptoms?
*
Fever
Headache
Rash
Chest pain
Cough
Shortness of breath
Nausea
Vomiting
Diarrhea
Blurred or double vision
Trouble falling asleep
Trouble staying asleep
None
By signing below, I acknowledge that I will take medication(s) as prescribed. I understand that altering my medications in any way may result in dismissal from the practice.
*
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