GAD-7
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Over the last 2 weeks, how often have you been bothered by the following problems?
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9)
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Over the last 2 weeks. how often have you been bothered by aoy of the following problems?
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 fidgety 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 in some way
If you checked off any problems. how difflcult have these problems made It for you to do your work, take care of things at home, or get along with other people?
Please Select
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
PCL-5
Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then select one of the numbers to indicate how much you have been bothered by that problem in the past month.
Client Name
First Name
Last Name
In the past month, how much were you bothered by:
1. Repeated, disturbing, and unwanted memories of the stressful experience?
2. Repeated, disturbing dreams of the stressful experience?
3. Suddenly feeling or acting as If the stressful experience were actually happening again (as If you were actually back there reliving it)?
4. Feeling very upset when something reminded you of the stressful experience?
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
6. Avoiding memories, thoughts, or feelings related to the stressful experience?
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
8. Trouble remembering important parts of the stressful experience?
9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there Is something seriously wrong with me, no one can be trusted, the world Is completely dangerous)?
10. Blaming yourself or someone else for the stressful experience or what happened after It?
11. Having strong negative feallngs such as fear, horror, anger, guilt, or shame?
12. Loss of Interest In activities that you used to enjoy?
13. Feeling distant or cut off from other people?
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
15. Irritable behavior, angry outbursts, or acting aggressively?
16. Taking too many risks or doing things that could cause you hann?
17. Being "superalert'' or watchful or on guard?
20. Trouble falling or staying asleep?
Submit
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