Patient Information
What is your name?
*
First Name
Last Name
What is your birthday?
*
What is your birthday?
*
-
Month
-
Day
Year
Date
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Behavioral Health Integration
We like to provide holistic care for our patients, and because pain and loss of function can affect other aspects of your life, we ask that you fill out this brief screening questionnaire.
GAD
Over the last 2 weeks, how often have you been bothered by the following problems?
*
Rows
Not at all
Several days
More than half the days
Nearly every day
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
GAD Score
GAD Findings
You should consider seeing a counselor and/or psychiatrist. Here are list of options.
Please Select
Katie Boyd, Psy D.
CWE Theraphy
Shanon Harlow, Psy.D.
Parimal Patel, MD
Stacey Carter-Sand, Ph.D
Jeffrey Farb, PsyD
Address and Contact Information
Some techniques shown to be helpful in managing anxiety are deep breathing exercises, progressive muscle relaxation, and meditation. Would you like referral to a counselor or psychiatrist?
Yes
No, not at the moment
Do you want to be referred to a:
Counselors
Psychiatrists
Counselors
Please Select
Katie Boyd, Psy.D.
CWE Theraphy
Shanon Harlow, Psy.D.
Stacey Carter-Sand, Ph.D
Jeffrey Farb, PsyD
Psychiatrists
Please Select
Parimal Patel, MD
Shuo Qiu, MD
Address and Contact Information
Address and Contact Information
Empty when score is 0
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PHQ
Over the last 2 weeks, how often have you been bothered by the following problems?
*
Rows
Not at all
Several days
More than half the days
Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
PHQ-2 score
PHQ-2 Findings
Exercise has been shown to be as effective as medications for mild to moderate depression. Would you like referral to a counselor or psychiatrist?
Yes
No, not at the moment
Do you want to be referred to a:
Counselor
Psychiatrist
Counselor
Please Select
Katie Boyd, Psy.D.
CWE Theraphy
Shanon Harlow, Psy.D.
Stacey Carter-Sand, Ph.D
Jeffrey Farb, PsyD
Psychiatrist
Please Select
Parimal Patel, MD
Shuo Qiu, MD
Address and Contact Information
Address and Contact Information
You should consider seeing a psychiatrist. Here are list of options.
Please Select
Parimal Patel, MD
Shuo Qiu, MD
Address and Contact Information
Empty when score is 0
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Gender
*
Male
Female
Age between 16-45 years?
*
Yes
No
Family History of Substance Abuse
*
Rows
Yes
No
Alcohol
Illegal Drugs
Prescription Drugs
Personal History of Substance Abuse
*
Rows
Yes
No
Alcohol
Illegal Drugs
Prescription Drugs
Personal History of Sexual Abuse
*
Rows
Yes
No
Preadolescent Sexual Abuse
Personal History of Psychological Disease
*
Rows
Yes
No
ADD, OCD, bipolar, schizophrenia
Depression
Points
ORT Findings
Thank you for your responses
Empty when score is 0
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AUDIT
*
Rows
Never
Mothly or less
2-4 times a month
2-3 times a week
4 or more times a week
How often do you have a drink containing alcohol?
Rows
0 or 2
3 or 4
5 or 6
7 or 9
10 or more
How many drinks containing alcohol do you have on a typical day when you are drinking?
Rows
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often do you have six or more drinks on one occasion?
AUDIT Score
Findings
Are you interested in decreasing your alcohol use?
*
YES
NO
Your health is important. Let us know if you would like assistance in the future.
Here are a list of psychiatrist who can help treat you:
Please Select
Parimal Patel, MD
Shuo Qiu, MD
Address and Contact Info
Empty when score is 0
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Body Mass Index (BMI) Calculator
Enter Weight:
Enter Height:
Preferred Unit:
*
Imperial
Metric
Your Weight in Pounds:
*
Your Height in Feet:
*
Inches:
*
Your Weight in KG:
*
Your Height in Centimeters:
*
LETS SEE YOUR WEIGHT STATUS
Your Body Mass Index (BMI):
You Are:
Would you like help with:
*
Dieting
Exercise Program
Referral for advanced treatment
No, at the moment
Would you like help with:
*
Dieting
Exercise Program
Referral for advanced treatment (Bariatrics)
No, at the moment
Nutritionist
Please Select
Physical Therapy
Please Select
Tom Nuzum, Physical Therapist
Jonathan Gordon, PT
Eric Bellm, DPT
Bariatric surgeon
Please Select
Mercy Bariatric Center - St. Louis
St. Luke's Des Peres Hospital MyNewSelf Bariatrics
Empty when score is 0
Class Obesity
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TOBACCO USE (Do you currently smoke?)
*
Yes
No
How many cigarettes per day do you use?
Are you ready to quit?
Yes
No
Resources for quitting: 1-800-QUITNOW
Discuss with Dr. Patel about treatments to help with tobacco cessation
Your health is important. Let us know if you would like assistance in the future, as quitting is best for your long term health.
Quit
no quit
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Do you know your blood pressure?
Yes
No
Systolic (high number):
Diastolic (low number):
blood pressure
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Submit
Should be Empty: