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6
Questions
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HIPAA
Compliance
1
Patient Name
First Name
Last Name
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2
Patient Date of Birth
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Month
Day
Year
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3
Today's Date
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4
Answered By
Please give the name of person answering the questionnaire, if not answered by the patient.
First Name
Last Name
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5
Over the last 2 weeks, how often have you been bothered by any of the following problems?
*
This field is required.
Please only select one response per problem.
Not at all
Several days
More than half the days
Nearly everyday
Little interest or pleasure in doing things
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Feeling down, depressed, or hopeless
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Trouble falling or staying asleep, or sleeping too much
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Feeling tired or having little energy
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Poor appetite or overeating
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Feeling bad about yourself--- or that you are failure or have let yourself or your family down
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Trouble concentrating on things, such as reading the newspaper or watching television
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
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
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Thoughts that you would be better off dead or of hurting yourself in some way
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
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 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 have been moving around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in some way
Not at all
Row 0, Column 0
Several days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly everyday
Row 0, Column 3
Not at all
Row 1, Column 0
Several days
Row 1, Column 1
More than half the days
Row 1, Column 2
Nearly everyday
Row 1, Column 3
Not at all
Row 2, Column 0
Several days
Row 2, Column 1
More than half the days
Row 2, Column 2
Nearly everyday
Row 2, Column 3
Not at all
Row 3, Column 0
Several days
Row 3, Column 1
More than half the days
Row 3, Column 2
Nearly everyday
Row 3, Column 3
Not at all
Row 4, Column 0
Several days
Row 4, Column 1
More than half the days
Row 4, Column 2
Nearly everyday
Row 4, Column 3
Not at all
Row 5, Column 0
Several days
Row 5, Column 1
More than half the days
Row 5, Column 2
Nearly everyday
Row 5, Column 3
Not at all
Row 6, Column 0
Several days
Row 6, Column 1
More than half the days
Row 6, Column 2
Nearly everyday
Row 6, Column 3
Not at all
Row 7, Column 0
Several days
Row 7, Column 1
More than half the days
Row 7, Column 2
Nearly everyday
Row 7, Column 3
Not at all
Row 8, Column 0
Several days
Row 8, Column 1
More than half the days
Row 8, Column 2
Nearly everyday
Row 8, Column 3
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6
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?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
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