Adult Mental Health Questionnaire (with ROS)

Date

Please enter your First and Last Name:* This field is required.

First Name

Last Name

General* This field is required.Select any/all that you have experienced in the past 2 days:

NONE

Feeling Tired

Feeling Weak

Fever or Chills

Body aches

Recent weight gain or loss

General

Ear, Nose, and Throat* This field is required.Select any/all that you have experienced in the past 2 days:

NONE

Nasal congestion

Difficulty swallowing

Nasal Drainage

Sore throat

Earache

ENT

Urinary* This field is required.Select any/all that you have experienced in the past 2 days:

NONE

Pain during urination

Urinating more than 1 time at night

Increased/decreased urination

Blood in urine

Urinary

Gastrointestinal* This field is required.Select any/all that you have experienced in the past 2 days:

NONE

Decreased appetite

Abdominal pain

Nausea or vomiting

Diarrhea

Constipation

Heartburn

Blood in stool

Gastrointestinal

Skin and Musculoskeletal* This field is required.Select any/all that you have experienced in the past 2 days:

NONE

New or changing moles

Neck pain

Joint pain

Back pain

Skin and Musculoskeletal

Chest* This field is required.Select any/all that you have experienced in the past 2 days:

NONE

Cough

Excessively loud snoring

Shortness of breath

Heart racing

Heart skipping beats

Chest pain or discomfort

Chest tightness

Chest

Endocrinology* This field is required.Select any/all that you have experienced in the past 2 days:

NONE

Easy bruising

Excessive thirst

Excessive sweating

Temperature intolerance

Sweating heavily at night

Endocrinology

Neurologic and Eyes* This field is required.Select any/all that you have experienced in the past 2 days:

NONE

Headache

Ringing in the ears

Dizziness

Numbness or tingling

Decrease in strength

Red eyes

Sleep disturbances

Depression and/or Anxiety

Neurologic and Eyes

GynecologySelect any/all that you have experienced in the past 2 days:

NONE

Unexplained vaginal bleeding

Vaginal pain, itching, or burning

Vaginal Discharge

Gynecology

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

Not at all (0-1 days)

Several days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)

Over the past two weeks, how often have you felt down, depressed, or hopeless?* This field is required.

Not at all (0-1 days)

Several days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)

Other

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

Not at all (0-1 days)

Several Days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)

Over the last 2 weeks, how often have you felt tired or had little energy?* This field is required.

Not at all (0-1 days)

Several Days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)

Over the last 2 weeks, how often have you experienced a poor appetite or overeating?* This field is required.

Not at all (0-1 days)

Several Days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)

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

Not at all (0-1 days)

Several Days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)

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

Not at all (0-1 days)

Several Days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)

Over the last 2 weeks, how often have you felt that you are moving or speaking so slowly that others may notice. Or being more fidgety or restless than usual?* This field is required.

Not at all (0-1 days)

Several Days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)

Over the last 2 weeks, how often have you had thoughts that you would be better off dead or hurting yourself in some way?* This field is required.

Not at all (0-1 days)

Several Days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)

PHQ-9 Calculation

On a scale from 1 - 10, how would you rate your depression over the last 2 weeks?* This field is required.

Have you had recent (within the last 2 weeks) or current thoughts of self-harm?* This field is required. (ex. cutting, scratching, burning)

YESNO

Have you had recent (within the last 2 weeks) or current thoughts of trying to take your own life?* This field is required.

YESNO

Have you self-harmed in the past?* This field is required.(ex. cutting, scratching, burning)

YESNO

Have you attempted suicide in the past?* This field is required.

YESNO

Have you had recent or current thoughts of harming other(s)?* This field is required.

YESNO

Whom have you thought about harming?

On a scale from 1 - 10, how would you rate your fatigue over the last 2 weeks?

On a scale from 1 - 10, how would you rate your insomnia (difficulty sleeping) over the last 2 weeks?

Are you currently being treated for ADHD?* This field is required.

YESNO

Do you experience trouble concentrating or paying attention?* This field is required.

YESNO

How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?

Never

Rarely

Sometimes

Often

Very Often

How often do you have difficulty unwinding and relaxing when you have time to yourself?

Never

Rarely

Sometimes

Often

Very Often

When you are 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?

Never

Rarely

Sometimes

Often

Very Often

How often do you put things off until the last minute?

Never

Rarely

Sometimes

Often

Very Often

How often do you depend on others to keep your life in order and attend to details?

Never

Rarely

Sometimes

Often

Very Often

On a scale from 1 - 10, how would you rate your anxiety over the last 2 weeks?

Over the last 2 weeks, how often have you experienced feeling nervous, anxious, or on edge?* This field is required.

Not at all (0-1 days)

Several Days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)

Over the last 2 weeks, how often have you experienced not being able to stop or control worrying?* This field is required.

Not at all (0-1 days)

Several Days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)

Over the last 2 weeks, how often have you experienced worrying too much about different things?* This field is required.

Not at all (0-1 days)

Several Days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)

Over the last 2 weeks, how often have you experienced trouble relaxing?* This field is required.

Not at all (0-1 days)

Several Days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)

Over the last 2 weeks, how often have you experienced being so restless that it's hard to sit still?* This field is required.

Not at all (0-1 days)

Several Days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)

Over the last 2 weeks, how often have you experienced becoming easily annoyed or irritable?* This field is required.

Not at all (0-1 days)

Several Days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)

Over the last 2 weeks, how often have you felt afraid as if something awful might happen?* This field is required.

Not at all (0-1 days)

Several Days (2-6 days)

More than half the days (7-11 days)

Nearly every day (12-14 days)