Follow-up Patient Forms

SUMMIT BEHAVIORAL HEALTH

FOLLOW-UP PATIENT FORMS
Date *

Month Day Year
Date
Name *

First Name Last Name
Address (If changed recently)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email (If changed recently)
example@example.com
Mobile Phone Number (If changed recently)

Area Code Phone Number
Insurance Company Name (If changed recently)
Insurance ID (If changed recently)
Group ID (If changed recently)
Enter any other changes you want us to know of so we can update your profile:
PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

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

SELECTION

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 fidgety 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

Add Each Row Score Above And Input Total Below
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
Generalized Anxiety Disorder 7-item (GAD-7) scale

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

RESPONSE

1. Feeling nervous, anxious, or on edge

2. Not being able to stop or control worrying

3. Worrying too much about different things

4. Trouble relaxing

5. Being so restless that it's hard to sit still

6. Becoming easily annoyed or irritable

7. Feeling afraid as if something awful might happen

Add each row score above and input total below:
MEDICAL REVIEW OF SYSTEMS

Please list all physical symptoms:
VISUAL (If any)
HEARING (If any)
RESPIRATORY *

None Asthma Congestion Short of breath Wheezing Cough Other
Describe Other Respiratory If Applicable:
CARDIOVASCULAR *

None High blood pressure Low blood pressure Chest pain Palpitations Prior heart attack Fainting episodes Other
Describe Other Cardiovascular If Applicable:
EXCRETORY *

None Urinary/bladder infections Night-time infections Urine/stool incontinence Other
NEUROLOGICAL *

None Headaches/migraines Seizures Dizziness Tremors Memory issues One-sided body weakness Pins & needle sensation Past history of head injury Loss of consciousness
REPRODUCTIVE *

None HIV History of STD Sexual worries Birth control worries
ENDOCRINE *

None Diabetes Low blood sugar Thyroid dysfunction Swelling
GASTROINTESTINAL *

None Abdominal pain Nausea Vomiting Diarhhoea Weight loss/gain Constipation Increased/decreased appetite
MUSCULOSKELETAL *

None Back pain Joint pain Muscle tenderness/impairement
EPWORTH SLEEPINESS SCALE

How likely are you to doze off or fall asleep in the following situations? In contrast to just feeling tired, this refers to your usual way of life in recent times . Even if you have not done some of these things recently try to think through how you might have felt in each setting. Use the following scale to choose the most appropriate number for each situation:

Selection

Sitting and reading

Watching TV

Sitting inactive in a public place

Being a passenger in a motor vehicle for

an hour or more

Lying down in the afternoon

Sitting and talking to someone

Sitting quietly after lunch (no alcohol)

Stopped for a few minutes in traffic

While driving

Add Each Row Score Above And Input Total Below:
Should be Empty:

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SUMMIT BEHAVIORAL HEALTH

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

MEDICAL REVIEW OF SYSTEMS

EPWORTH SLEEPINESS SCALE