Daily Self Inventory - IOP
Name
*
First Name
Last Name
1. Have you had any thoughts of hurting yourself or anyone else in the last 24 hours?
*
NO, I have not had any thoughts of hurting myself or others.
YES
2. Have you been seeing or hearing things other people may not be?
*
YES
NO
3. Do you think other people are out to get you?
*
YES
NO
4. How well is your sleep?
*
WELL
FAIR
POOR
MEDICATION TAKEN FOR SLEEP
5. How is your appetite?
*
GOOD
IMPROVING
POOR
6. Please rate your energy level below:
*
0 - No Energy
1
2
3
4
5 - Normal Energy
6
7
8
9
10 - Excessive Energy
7. Please rate your level of depression below:
*
0 - No Depression
1
2
3
4
5 - Moderate Depression
6
7
8
9
10 - Severe Depression
8. Please rate your level of anxiety below:
*
0 - No Anxiety
1
2
3
4
5 - Moderate Anxiety
6
7
8
9
10 - Severe Anxiety
9. Please rate your level of agitation below:
*
0 - No Agitation
1
2
3
4
5 - Moderate Agitation
6
7
8
9
10 - Severe Agitation
10. Have you had an anxiety attack in the last 24 hours?
*
NO
YES
11. Have you used any substances or consumed alcohol in the last 24 hours?
*
NO
YES
Indicate the address you will be located at during your tele-health sessions:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Indicate the best phone number to reach you at today:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: