Wellness Assessment

Wellness Assessment - Adult
Client Name
Completing this brief questionnaire will help us provide services that meet your needs. Answer each question as best you can and then review your responses with your clinician. Please shade circles like this
Date of Birth

MonthDayYear
Date
Today's Date (mm/dd/yy)
Visit #:

1 or 23 to 5Other
For questions 1-16, please think about your experience in the past week.

How much did the following problems bother you?

	Not at All	A Little	Somewhat	A Lot
1. Nervousness or shakiness
2. Feeling sad or blue
3. Feeling hopeless about the future
4. Feeling everything is an effort
5. Feeling no interest in things
6. Your heart pounding or racing
7. Trouble sleeping
8. Feeling fearful or afraid
9. Difficulty at home
10. Difficulty socially
11. Difficulty at work or school

13. I can deal with my problems

	Strongly Agree	Agree	Disagree	Strongly Disagree
12. I feel good about myself
14. I am able to accomplish the things I want
15. I have friends or family that I can count on for help

16. In the past week, approximately how many drinks of alcohol did you have?
Drinks
Please answer the following questions only if this is your first time completing this questionnaire.
Please answer the following questions only if this is your first time completing this questionnaire.
17. In general, would you say your health is:

Very GoodGoodFairPoorExcellent
18. Please indicate if you have a serious or chronic medical condition:

AsthmaDiabetesHeart DiseaseBack Pain or Other Chronic PainOther
Days

19. In the past 6 months, how many times did you visit a medical doctor?None12-3120. In the past month, how many days were you unable to work because of your physical or (answer only if employed) mental health?4-56
21. In the past month, how many days were you able to work but had to cut back on how answer only if much you got done because of your physical or mental health?

YesNo22. In the past month have you ever felt you ought to cut down on your drinking or drug use?
24. In the past month have you felt bad or guilty about your drinking or drug use?

23. In the past month have you ever felt annoyed by people criticizing your drinking or drug use?YesNoYesNo
24. In the past month have you felt bad or guilty about your drinking or drug use?

Days21. In the past month, how many days were you able to work but had to cut back on how answer only if much you got done because of your physical or mental health?
Should be Empty:

Wellness Assessment - Adult