Primary Care Supplemental Intake

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

Rows	Not at All (0)	Several Days (1)	More than half the days (2)	Nearly every day (3)
(GAD-2) Feeling nervous, anxious or on edge
(GAD-2) Not being able to stop or control worrying
(PHQ-2) Little interest or pleasure in doing things
(PHQ-2) Feeling down, depressed, or hopeless

Now I am going to ask you some questions about your use of alcoholic beverages during this past year.
NeverMonthly or less2-4 times per month2-3 times per week4 or more times per week
1-23-45-67-910+I do not drink alcohol
NeverLess than monthlyMonthlyWeeklyDaily or almost daily
Zero timesOne or two timesThree or more times
YesNo
By whom?

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

Rows	Not at All (0)	A little bit (1)	Moderately (2)	Quite a bit (3)	Extremely (4)
(PCL-C) Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?
(PCL-C) Feeling very upset when something reminded you of a stressful experience from the past?

STAYING HEALTHY ASSESSMENT

ADULT
Please answer all the questions on this form as best you can. Mark “Skip” if you do not know an answer or do not wish to answer. Be sure to talk to the doctor if you have questions about anything on this form. Your answers will be protected as part of your medical record.
YesNoSkip
YesNoSkip
YesNoSkip
YesNoSkip
NoYesSkip
NoYesSkip
NoYesSkip
YesNoSkip
YesNoSkip
NoYesSkip
NoYesSkip
By whom?
YesNoSkip
NoYesSkip
YesNoSkip
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NoYesSkip
NoYesSkip
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Please describe:
STAYING HEALTHY ASSESSMENT

SENIOR
Please answer all the questions on this form as best you can. Mark “Skip” if you do not know an answer or do not wish to answer. Be sure to talk to the doctor if you have questions about anything on this form. Your answers will be protected as part of your medical record.
YesNoSkip
YesNoSkip
YesNoSkip
YesNoSkip
NoYesSkip
NoYesSkip
NoYesSkip
NoYesSkip
YesNoSkip
YesNoSkip
NoYesSkip
NoYesSkip
NoYesSkip
NoYesSkip
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YesNoSkip
NoYesSkip
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YesNoSkip
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NoYesSkip
Please describe:
Should be Empty: