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  • Behavioral Health Check in Forms

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of completion*
     - -
    2 digit month, 2 digit day, 4 digit year

  • PATIENT HEALTH QUESTIONNAIRE- 9(PHQ-9)

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

  • 1. Little interest or pleasure indoing 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 hurting yourself in some way*
  • If you checked 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?*

  • Generalized Anxiety Disorder 7-item (GAD-7) scale

  • Over the last 2 weeks, how often have you been bothered by any of 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's hard to sit still*
  • 6. Becoming easily annoyed or irritable*
  • 7. Feeling afraid as if something awful might happen*
  • If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?*

  • CAGE-AID Questionnaire

  • When thinking about drug use, include illegal drug use and the use of prescription drug use other than prescribed.

  • 1. Have you ever felt you ought to cut down on your drinking or drug use?*
  • 2. Have people annoyed you by criticizing your drinking or drug use?*
  • 3. Have you ever felt bad or guilty about your drinking or drug use?*
  • 4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?*
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