ADULT Questionnaire - Patient Health Questionnaire

Patient Health Questionnaire (PHQ9)
Name

First NameLast Name
Date

MonthDayYear

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

Type a question

	Yes	No
1. Has there ever been a period of time when you were not your usual self and...
...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
...you were so irritable that you shouted at people or started fights or arguments?
...you felt much more self-confident than usual?
...you got much less sleep than usual and found you didn’t really miss it?
...you were much more talkative or spoke much faster than usual?
...thoughts raced through your head or you couldn’t slow your mind down?
...you were so easily distracted by things around you that you had trouble concentrating or staying on track?
...you were much more active or did many more things than usual?
...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
...you were much more interested in sex than usual?
...you did things that were unusual for you or that other people might have thought were excessive, foolish or risky?
...spending money got you or your family in trouble?
...you had much more energy than usual?

Total Number of "YES" responses

	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?

3. How much of a problem did any of these cause you – like being unable towork; having family, money or legal troubles; getting into arguments orfights?

No ProblemMinor ProblemModerate ProblemSerious Problem

	Yes	No
3. Have any of your blood relatives (i.e. children, siblings, parents,grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
5. Has a health care professional ever told you that you have manic- depressive illness or bipolar disorder?

Are you living with Adult ADHD?

Many adults have been living with Adult Attention Deficit/Hyperactive Disorder (Adult ADHD) and don’t recognize it.These symptoms are often mistaken for a stressful life. If you’ve felt this type of frustration most of your life, you mayhave Adult ADHD - a condition your doctor can help diagnose and treat.The following questionnaire can be used as a starting point to help you recognize the signs/symptoms of Adult ADHD butis not meant to replace consultation with a trained healthcare professional. An accurate diagnosis can only be madethrough a clinical evaluation. Regardless of the questionnaire results, if you have concerns about diagnosis andtreatment of Adult ADHD, please discuss your concerns with your physician.
This Adult Self-Report Scale-V1.1 (ASRS-V1.1) Screener is intended for people aged 18 years or older.

Adult Self Report Scale

Check the box that best describes how you have feltand conducted yourself over the past 6 months.Please give the completed questionnaire to yourhealthcare professional during your nextappointment to discuss the results.

	Never	Rarely	Sometimes	Often	Very Often
1.How often do you have trouble wrapping up the final detail of a project, once the challenging parts have been done?
2. How often do you have difficulty getting things done 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 a long time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?

GAD-7 ; Over the last 2 weeks, how often have you been bothered by the following problems?

	Not at all-0	Several Days-1	More than half the days-2	Nearly every day-3
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

Add Columns for Totals

Several Days

More than half the days

Nearly every day

Total: 0/ 100
Audit – C Questionnaire
1. How often do you have drinks containing alcohol?

NeverMonthly or Lesss2-4 times a month2-3 times a week4 or more times a week
2. How many standard drinks containing alcohol do you have on a typical day?

01 or 23 or 45 or 67 to 910 or more
3. How often do you have six or more drinks on one occasion?

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
Should be Empty:

Patient Health Questionnaire (PHQ9)

Are you living with Adult ADHD?

This Adult Self-Report Scale-V1.1 (ASRS-V1.1) Screener is intended for people aged 18 years or older.

Audit – C Questionnaire