Behavioral Health Integration Initial - CA

  • Patient Information

  • What is your birthday?*
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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

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  • 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?
  • Do you want to be referred to a:

  • PHQ

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  • Exercise has been shown to be as effective as medications for mild to moderate depression. Would you like referral to a counselor or psychiatrist?
  • Do you want to be referred to a:
  • Gender*
  • Age between 16-45 years?*
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  • Thank you for your responses

  • AUDIT

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  • Are you interested in decreasing your alcohol use?*
  • Your health is important. Let us know if you would like assistance in the future.

  • Body Mass Index (BMI) Calculator

  • Enter Weight:

    Enter Height:

  • Preferred unit:*

  • LETS SEE YOUR WEIGHT STATUS

  • Would you like help with:*
  • Would you like help with:*
  • TOBACCO USE (Do you currently smoke?)*
  • Are you ready to quit?
    • Resources for quitting: 1-800-QUITNOW
    • Discuss with your Doctor today 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.
  • Do you have a history of palpitations, arrhythmias, heart failure or heart attack? Did you ever have a monitor of your heart that you wore? Do you have an implanted cardiac device?*
  • Would you like to talk to a doctor in the clinic about this?*

  • Thank you. We will schedule you with our providers.

  • Ok, let us know if we can be of service in the future.

  • Do you know your blood pressure?
  • Should be Empty: