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30
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1
Please Enter your ABHS ID Number
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2
Today's Date
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3
Feeling sad or down
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4
Having self-critical thoughts
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5
Feeling low interest in doing anything
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6
Feeling a low level of energy
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7
Feeling anxious or afraid
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8
Worrying about things over and over
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9
Thinking about ending your life or wishing it would end
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10
Feeling afraid about body sensations or symptoms
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11
Having panic attacks
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12
Feeling irritable or angry
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13
Having sleep problems
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14
Having appetite problems
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15
Having difficulty concentrating
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16
Experiencing intrusive / obsessive thoughts
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17
Feeling distressed about intrusive / obsessive thoughts
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18
Performing rituals (to relieve obsessions / anxiety)
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19
Avoiding people, situations, or activities that make you feel anxious
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20
Avoiding people, situations, or activities due to low energy
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21
Suddenly remembering frightening experiences from your past
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22
Experiencing physical pain
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23
Using alcohol, medications, or other substances recreationally
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24
Feeling unable to complete important daily activities
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25
Did you have specific tasks (i.e., "homework") that you committed to complete since your last session?
*
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Please indicate "Yes" or "No."
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26
How much actual time did you spend doing the homework?
Please enter a short response, indicating minutes or hours.
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27
How much effort did you put into this homework?
Please enter a number from 0-100 indicating the percentage of effort you felt as if you made.
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28
How much of the homework did you complete?
Please enter a number from 0-100 indicating the percentage of homework you completed.
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29
Have you had any changes in medications since your last appointment?
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Please indicate "Yes" or "No."
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30
Total Score
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31
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