GAD-7 / PHQ-9

Name

First NameLast Name
Date

MonthDayYear
Date
GAD-7
Over the last 2 weeks, how often have you been bothered by the following problems?
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 is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9)
Over the last 2 weeks, how often have you been bothered by the following problems?
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or 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 in some way
If you checked off any problems. how difflcult have these problems made It for you to do your work, take care of things at home, or get along with other people?
Alcohol Use Disorders Identification Test-Concise (AUDIT-C)

General Instructions: The AUDIT-C is a brief alcohol screening instrument. Please give a response for each question.
1. How often do you have a drink containing alcohol?
2. How may standard drinks containing alcohol do you have on a typical day?
3. How often do you have six (6) or more drinks on one occasion?
ASRS V1.1 Questionnaire
Please answer the questions below, rating yourself on each of the criteria. As you answer each question, select the single choice that best describes how you have felt and conducted yourself over the past 6 months. This form can be be submitted and can be discussed during your next appointment with Dr. Sherman.

	Never	Rarely	Sometimes	Often	Very Often
1. How often do you have trouble wrapping up the final details of a project, once thechallenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay gettingstarted?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for along time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
7. How often do you make careless mistakes when you have to work on a boring or difficult project?
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
9. How often do you have difficulty concentrating on what people say to you, even when theyare speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?
11. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or in other situations in which you areexpected to stay seated?
13. How often do you feel restless or fidgety?
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
15. How often do you find yourself talking too much when you are in social situations?
16. When you’re in a conversation, how often do you find yourself finishing the sentences of thepeople you are talking to, before they can finish it themselves?
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
18. How often do you interrupt others when they are busy?

Should be Empty:

GAD-7

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

PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9)

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

Alcohol Use Disorders Identification Test-Concise (AUDIT-C)

ASRS V1.1 Questionnaire