Screening Form

Name

First NameLast Name

Date

Patient Health Questionnaire: Over the last 2 weeks, how often have you been bothered by any of the following problems?

Rows	Not At All	Several Days	More Than Half Days	Nearly Everyday
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself- or that you are a failure and have let yourself or your family down
Trouble concentrating on things such as reading the newspaper or watching television
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
Thoughts that you would be better off dead, or of hurting yourself

Not DifficultSomewhat DifficultVery DifficultExtremely Difficult

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

Rows	Not at All	Several Days	More than Half the Days	Nearly Everyday
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed, or the opposite - being so fidgety or restless that you've been moving around a lot more than usual
Thoughts that you would be better off dead, or hurting yourself in some way

Patient Stress Questionnaire : Over the last two weeks , how often have you been bothered by any of the following problems?

Rows	Not at All	Several Days	More than Half the Days	Nearly Everyday
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
Are you currently in any physical pain?

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month , you:

Rows	Not at All	Several Days	More than Half the Days	Nearly Everyday
Have had nightmares about it or thought about it when you did not want to?
Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
Were constantly on guard, watchful, or easily startled?
Felt numb or detached from others, activities, or your surroundings?

Drinking alcohol can affect your health. This is especially important if you take certain medications. We want to help you stay healthy and lower your risk for the problems that can be caused by drinking. These questions are about your drinking habits. We’ve listed the serving size of one drink below.

Rows	Never	Monthly or Less	2-4 Times a Month	2-3 Times per Week	4+ Times per Week
How often do you have one drink containing alcohol?

Rows	1-2	3-4	5-6	7-9	10 or More
How many drinks containing alcohol do you have ona typical day when you are drinking?

Rows	Never	Less than Monthly	Monthly	Weekly	Daily or Almost Daily
How often do you have one drink containing alcohol?
How often do you have four or more drinks on one occasion?
How often during the last year have you done any of the following: Found that you were not able to stop drinking once you had started?
Failed to do what was normally expected from you because of drinking?
Needed a first drink in the morning to get yourself going after heavy drinking?
Had a feeling of guilt or remorse after drinking?
Been unable to remember what happened the night before because you had been drinking?

Rows	No	Yes	Yes, but not in the last year	Yes, during the last year
Have you or someone else been injured as a result of your drinking?
Has a relative, friend, doctor or other health worker been concerned about your drinking or suggested you cut down?

Rows	Yes	No
...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
...you were so irritable that you shouted at people or started fights or arguments?
...you felt much more self-confident than usual?
...you got much less sleep than usual and found that you didn’t really miss it?
...you were more talkative or spoke much faster than usual?
...thoughts raced through your head or you couldn’t slow your mind down?
...you were so easily distracted by things around you that you had trouble concentrating or staying on track?
...you had more energy than usual?
...you were much more active or did many more things than usual?
...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
...you were much more interested in sex than usual?
...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
...spending money got you or your family in trouble?
If you checked YES to more than one of the above, have several of these ever happened during the same period of time?

Rows	No Problems	Minor Problems	Moderate Problems	Serious Problems
How much of a problem did any of these cause you - like being unable to work; having family, money or legal troubles; getting into arguments or fights?

Be sure to consider your entire life (growing up as well as adulthood) as you go through the list of events.

Rows	Happened to me	Witnessed it	Learned about it	Not sure	Doesn't apply
Natural disaster (for example, flood, hurricane, tornado, earthquake)
Fire or explosion
Transportation accident (for example, car accident, boat accident, train wreck, plane crash)
Serious accident at work, home, or during recreational activity
Exposure to toxic substance (for example, dangerous chemicals, radiation)
Physical assault (for example, being attacked, hit, slapped, kicked, beaten up)
Assault with a weapon (for example, being shot, stabbed, threatened with a knife, gun, bomb)
Sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm)
Other unwanted or uncomfortable sexual experience
Combat or exposure to a war-zone (in the military or as a civilian)
Captivity (for example, being kidnapped, abducted, held hostage, prisoner of war)
Life-threatening illness or injury
Severe human suffering
Sudden, violent death (for example, homicide, suicide)
Sudden, unexpected death of someone close to you
Serious injury, harm, or death you caused to someone else
Any other very stressful event or experience

During that month, how often did you feel

Rows	All of the time	Most of the time	Some of the time	A little of the time	None of the time
tired out for no good reason?
...nervous?
...so nervous that nothing could calm you down?
...hopeless?
...restless or fidgety?
...so restless that you could not sit still?
...depressed?
...so depressed that nothing could cheer you up?
...that everything was an effort?
...worthless?

The last ten questions asked about feelings that might have occurred during the past 30 days. Taking them altogether, did these feelings occur More often in the past 30 days than is usual for you, about the same as usual, or less often than usual? (If you never have any of these feelings, circle response option “4.”)

AlotSomeA Little Bit

About the Same

A Little BitSomeAlot

During the past 30 days, how many days out of 30 were you totally unable to work orcarry out your normal activities because of these feelings?

Number of Days

Not counting the days you reported in response to Q3, how many days in the past30 were you able to do only half or less of what you would normally have been ableto do, because of these feelings?

Number of Days

During the past 30 days, how many times did you see a doctor or other healthprofessional about these feelings?

Number of Times

Rows	All of the time	Most of the time	Some of the time	A little of the time	None of the time
During the past 30 days, how often have physical health problems been the main cause of these feelings?

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

Rows	Not at all sure	Several days	Over half the days	Nearly everyday
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

Not DifficultSomewhat DifficultVery DifficultExtremely Difficult

Rows	Yes	No
Have you wished you were dead or wished you could go to sleep and not wake up?
Have you actually had any thoughts of killing yourself?
Have you been thinking about how you might kill yourself?
Have you had these thoughts and had some intention of acting on them?
Have you started to work or worked out the details of how to kill yourself and do you intend to carry out this plan?
Have you done anything, started to do anything, or prepared to do anything to end your life?

Screening Form

Patient Health Questionnaire

Patient Stress Questionnaire

Substance Abuse Questionnaire

Mood Disorder Questionnaire

Life Events Checklist

K10+

Generalized Anxiety Disorder

Suicide Questionnaire