New Pt Assessments

New Patient Assessments (Part 3 of 3)

Allow 10 min to complete
Patient Name*

First NameLast Name
Patients Date of Birth*

MonthDayYear
Date
Patient Age in years (as of today)*
This is the last step when becoming a new patient. You will complete a series of assessments which are needed for your new patient appointment.

	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
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 figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

	Not At All	Mildly but it didn’t bother me much	Moderately - it wasn’t pleasant at times	Severely – it bothered me a lot
Numbness or tingling
Feeling hot
Wobbliness in legs
Unable to relax
Fear of worst happening
Dizzy or lightheaded
Heart pounding/racing
Unsteady
Terrified or afraid
Nervous
Feeling of choking
Hands trembling
Shaky / unsteady
Fear of losing control
Difficulty in breathing
Fear of dying
Scared
Indigestion
Faint / lightheaded
Face flushed
Hot/cold sweats

	Never	Rarely	Sometimes	Often	Very Often
1. How often do you make careless mistakes when you have to work on a boring or difficult project?
2. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
3. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
4. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
5. How often do you have difficulty getting things in order when you have to do a task that requires organization?
6. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
7. How often do you misplace or have difficulty finding things at home or at work?
8. How often are you distracted by activity or noise around you?
9. How often do you have problems remembering appointments or obligations?

	Never	Rarely	Sometimes	Often	Very Often
10. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
11. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
12. How often do you feel restless or fidgety?
13. How often do you have difficulty unwinding and relaxing when you have time to yourself?
14. How often do you feel overly active and compelled to do things, like you were driven by a motor?
15. How often do you find yourself talking too much when you are in social situations?
16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
18. How often do you interrupt others when they are busy?

New Patient Assessments (Part 3 of 3)

	Yes	No
...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
...you were so irritable that you shouted at people or started fights or arguments?
...you felt much more self-confident than usual?
...you got much less sleep than usual and found you didn’t really miss it?
...you were much more talkative or spoke much faster than usual?
...thoughts raced through your head or you couldn’t slow your mind down?
...you were so easily distracted by things around you that you had trouble concentrating or staying on track?
...you had much more energy than usual?
...you were much more active or did many more things than usual?
...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
...you were much more interested in sex than usual?
...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
...spending money got you or your family into trouble?