CALTMS - HAM-A + PHQ-9 (ver 2)

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First, please tell us your name.* This field is required.All information is securely stored and confidential.

First Name

Last Name

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Your Cell Number* This field is required.Used to verify your health record

Please enter a valid phone number.

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How would you rate your Anxious Mood?Please choose on a scale of 0 to 4 0 = Not present to 4 = Severe Anxious Mood (Worries, Anticipates the worst)

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TensionPlease choose on a scale of 0 to 4 0 = Not present to 4 = Severe Tension (Startles, Cries easily, Restless, Trembling)

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FearsPlease choose on a scale of 0 to 4 0 = Not present to 4 = Severe Fears (Fear of the dark, Fear of strangers, Fear of being alone, Fear of animals)

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InsomniaPlease choose on a scale of 0 to 4 0 = Not present to 4 = Severe Insomnia (Difficulty falling asleep or staying asleep, Difficulty with nightmares)

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IntellectualPlease choose on a scale of 0 to 4 0 = Not present to 4 = Severe Intellectual (Poor concentration, Memory impairment)

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Depressed MoodPlease choose on a scale of 0 to 4 0 = Not present to 4 = Severe Depressed Mood (Decreased interest in activities, Anhedonia or loss of pleasure)

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Somatic Complaints: MuscularPlease choose on a scale of 0 to 4 0 = Not present to 4 = Severe Somatic Complaints: Muscular (Muscle aches or pains, Bruxism- grinding teeth or clenching jaw)

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Somatic Complaints: SensoryPlease choose on a scale of 0 to 4 0 = Not present to 4 = Severe Somatic Complaints: Sensory (Tinnitus or ringing of ears, Blurred vision)

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Cardiovascular SymptomsPlease choose on a scale of 0 to 4 0 = Not present to 4 = Severe Cardiovascular Symptoms (Tachycardia, Palpitations, Chest pain, Feeling faint)

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Respiratory SymptomsPlease choose on a scale of 0 to 4 0 = Not present to 4 = Severe Respiratory Symptoms (Chest pressure, Choking sensation, Shortness of breath)

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Gastrointestinal SymptomsPlease choose on a scale of 0 to 4 0 = Not present to 4 = Severe Gastrointestinal Symptoms (Dysphagia, Nausea or vomiting, Constipation, Weight loss, Abdominal fullness)

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Genitourinary SymptomsPlease choose on a scale of 0 to 4 0 = Not present to 4 = Severe Genitourinary Symptoms (Urinary frequency or urgency, Dysmenorrhea, Impotence)

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Autonomic SymptomsPlease choose on a scale of 0 to 4 0 = Not present to 4 = Severe Autonomic Symptoms (Dry mouth, Flushing, Pallor, Sweating)

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Over the past 2 weeks, how often have you experienced the following?* This field is required.Little interest or pleasure in doing things

Nearly every day

More than half the days

Several days

Not at all

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Feeling down, depressed, or hopeless* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

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Trouble falling or staying asleep, or sleeping too much* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

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Feeling tired or having little energy* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

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Poor appetite or overeating* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

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Feeling bad about yourself...or that you are a failure or have let yourself or your family down* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

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Trouble concentrating on things, such as reading, or watching television* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

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Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

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Thoughts that you would be better off dead, or of hurting yourself* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

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How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?* This field is required.Last question for the Depression Quiz.

Extremely difficult

Very difficult

Somewhat difficult

Not difficult at all

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Results of your HAM-AThe Hamilton Anxiety Scale (13 questions) is designed for Anxiety

Out of 52. Based on HAM-A.

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Results of your PHQ-9The Patient Health Questionnaire (9 questions) is designed for Depression

Out of 27. Based on PHQ-9.

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