Past Treatment History
MEDICATION TRIALS (Include doses, only medications used during this mood episode): Usually need two different classes and two augmentation trials.
THERAPY TRIAL (During this mood episode):
Please type or upload an up-to-date medication list and list of allergies.
Please answer each question to the best of your ability.
This instrument is designed for screening purposes only and not to be used as a diagnostic tool. Permission for use granted by RMA Hirschfeld, MD
Copyright C 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MDO is a trademark of Pfizer Inc.
Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097.
The following questions concern information about your potential involvement with drugs not including alcoholic beverages during the past 12 months. Carefully read each statement and decide if your answer is "Yes" or "No". Then, circle the appropriate response beside the question. In the statements "drug abuse" refers to (1) the use of prescribed or over the counter drugs in excess of the directions and (2) any non-medical use of drugs. The various classes of drugs may include: cannabis (e.g. marijuana, hash), soivents, tranquillizers (e.g. Valium), barbiturates, cocaine, stimulants (e.g. speed), hallucinogens (e.g. LSD) or narcotics (e.g. heroin Remember that the questions do not include
Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right.