Name
*
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Adverse Childhood Experience (ACE)
Finding your ACE Score
1. Did a parent or other adult in the household often... Swear at you, insult you, put you down, or humiliate you? OR Act in a way the made you afraid that you might get physically hurt?
*
Yes
No
2. Did a parent or other adult in the household often... Push. grab, slap, or throw something at you? OR Ever hit you so hard that you had marks or were injured?
*
Yes
No
3. Did an adult at least 5 years older than you ever... Touch or fondle you or have you touch their body in a sexual way? OR Try to or actually have oral, anal, or vaginal sex with you?
*
Yes
No
4. Did you often feel that... No one in your family loved you or thought you were important or special? OR Your family didn't look out for each other, feel close to each other, or support each other?
*
Yes
No
5. Did you often feel that... You didn't have enough to eat, had to wear dirty cloths, and had no one to protect you? OR Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
*
Yes
No
6. Were your parents ever separated or divorced?
*
Yes
No
7. Was you mother or stepmother: Often pushed, grabbed, slapped, or had something thrown at her? or Sometime or often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
*
Yes
No
8. Did you live with anyone who was a problem drinker or alcoholic or used street drugs?
*
Yes
No
9. Was a household member depressed or mentally ill or did a household member attempt suicide?
*
Yes
No
10. Did a household member go to prison?
*
Yes
No
Now ADD up your "Yes" answers and enter the number below:
*
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Mood Disorder Questionnaire (MDQ)
Please answer each question as best as you can.
1. Has there ever been a period of time where you were not you usual self and......
... you felt so good or hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
*
Yes
No
... you were so irritable that you shouted at people or started fights or arguments?
*
Yes
No
... you felt much more self-confident than usual?
*
Yes
No
... you got much less sleep than usual and found you didn't really miss it?
*
Yes
No
... you were much more talkative or spoke faster than usual?
*
Yes
No
... thoughts raced though your head or you couldn't slow your mind down?
*
Yes
No
... you were easily distracted by things around you that you had trouble concentrating or staying on track?
*
Yes
No
... you had much more energy than usual?
*
Yes
No
... you were much more active or did many more things than usual?
*
Yes
No
... you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
*
Yes
No
... you were much more interested in sex than usual?
*
Yes
No
... you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
*
Yes
No
... spending money got you or your family in trouble?
*
Yes
No
2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? (Please check 1 response only)
*
Yes
No
3. How much of a problem did any of these cause you - like being able to work; having family, money, or legal troubles; getting into arguments or fights?
No Problem
Minor Problem
Moderate Problem
Serious Problem
(Select One Only)
4. Have any of your blood relatives (ie, children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
*
Yes
No
5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?
*
Yes
No
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Personal Drug Use Questionnaire (SOCRATES)
*
NO! Strongly Disagree (1)
No Disagree (2)
? Undecided or Unsure (3)
Yes Agree (4)
YES! Strongly Agree (5)
1. I really want to make changes in my use of drugs.
2. Sometimes I wonder if I am an addict.
3. If I don't change my drug use soon, my problems are going to get worse.
4. I have already started making some changes in my use of drugs.
5. I was doing drugs too much at one time, but I've managed to change that.
6. Sometimes I wonder if my drug use is hurting other people.
7. I have a drug problem.
8. I'm not just thinking about changing my drug use, I'm already doing something about it.
9. I have already changed my drug use, and I am looking for ways to keep from slipping back to my old pattern.
10. I have serious problems with drugs.
11. Sometimes I wonder if I am in control of my drug use.
12. My drug use is causing a lot of harm.
13. I am actively doing things now to cut down or stop my use of drugs.
14. I want help to keep from going back to the drug problems that i had before.
15. I know i have a drug problem.
16. There are times when I wonder if I use drugs too much.
17. I am an addict
18. I am working hard to change my drug use.
19. I have made some changes in my drug use, and I want some help to keep from going back to the way I used before.
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LEC-5 Standard Listed below are a number of difficult or stressful things that sometimes happen to people. Be sure to consider your entire life (growing up as well as adulthood) as you go through the list of events.
*
Happened to me
Witnessed it
Learned about it
Part of my job
Not sure
Doesn't apply
Natural disaster (flood, earthquake, hurricane, tornado, etc.)
Fire or Explosion
Transportation accident (car, boat, train, plane, etc.)
Serious accident at work, home, or during recreational activity
Exposure to toxic substance (dangerous chemicals, radiation, etc.)
Physical assault (bring attacked, hit, slapped, kicked, beaten up, etc.)
Assault with a weapon (being shot, stabbed, threatened with a knife, gun, bomb, etc.)
Sexual assault ( rape, attempted rape, made to perform any type of sexual act through force or threat of harm)
Other unwanted or uncomfortable sexual experience
Combat or exposure to war-zone (in the military or as a civilian)
Captivity (bring kidnapped, abducted, held hostage, prisoner of war, etc.)
Life-threatening illness or injury
Severe human suffering
Sudden violent death (homicide, suicide, etc.)
Sudden accidental death
Serious injury, harm, or death you caused to someone else
Any other very stressful event or experience
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Alcohol Use Disorders Identification Test-Concise (AUDIT-C)
General Instructions: The AUDIT-C is a brief alcohol screening instrument. Please give a response for each question.
1. How often do you have a drink containing alcohol?
Please Select
Never
Monthly
2 to 3 times a week
2 to 4 times a month
4 or more times a week
2. How may standard drinks containing alcohol do you have on a typical day?
Please Select
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
3. How often do you have six (6) or more drinks on one occasion?
Please Select
Daily or almost daily
Weekly
Monthly
Less than monthly
Never
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ASRS V1.1 Questionnaire
Please answer the questions below, rating yourself on each of the criteria. As you answer each questions, select the single choice that best describes how you have felt and conducted yourself over the past 6 months. This form can be be submitted and can be discussed during your next appointment with Dr. Sherman.
Never
Rarely
Sometimes
Often
Very Often
1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for along time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
7. How often do you make careless mistakes when you have to work on a boring or difficult project?
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
9. How often do you have difficulty concentrating on what people say to you, even when theyare speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?
11. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or in other situations in which you are expected to stay seated?
13. How often do you feel restless or fidgety?
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
15. How often do you find yourself talking too much when you are in social situations?
16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish it themselves?
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
18. How often do you interrupt others when they are busy?
Submit
GAD-7
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 (PHQ9)
Name
First Name
Last Name
Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Over the last 2 weeks, how often have you been bothered by and of the following problems?
Not at all-0
Several Days-1
More than half the days-2
Nearly every day-3
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, 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 figety 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
Add Columns for Totals
Several Days
More than half the days
Nearly every day
Total:
0
/
100
If you check off any problems, 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?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Total:
0
/
100
Submit
Should be Empty: