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
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
2. Feeling down, depressed or hopeless
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
3. Trouble falling or staying asleep, sleeping too much
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
4. Feeling tired or having little energy
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
5. Poor appetite or overeating
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
7. Trouble concentrating on things, such as reading the newspaper or watching television
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
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
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
9. Thoughts that you would be better off dead, or of hurting yourself
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
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
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
2. Not being able to stop or control worrying
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
3. Worrying too much about different things
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
4. Trouble relaxing
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
5. Being so restless that it's hard to sit still
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
6. Becoming easily annoyed or irritable
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
7. Feeling afraid as if something awful might happen
0 (Not at all)
1 (Several days)
2 (More than half the days)
3 (Nearly every day)
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
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Watching TV
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Sitting inactive in a public place
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Being a passenger in a motor vehicle for
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
an hour or more
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Lying down in the afternoon
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Sitting and talking to someone
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Sitting quietly after lunch (no alcohol)
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Stopped for a few minutes in traffic
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
While driving
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Add Each Row Score Above And Input Total Below:
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