Screening Questionnaires

1
Before You Begin

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2
Full Name* This field is required.
First Name
Last Name
3
Email* This field is required.Your submission confirmation will be directed to this email
example@example.com
4
Date of Birth* This field is required.
Month
Day
Year
5
What is the purpose of this report?* This field is required.Select one.
FAA Evaluation to confirm resolution of past diagnoses of depression
FAA Evaluation to confirm resolution of past diagnoses of depression and PTSD
Nexus Letter to confirm PTSD
Nexus Letter to confirm depression and PTSD
6
Over the last 2 weeks, how often have you been bothered by any of the following problems? * This field is required.
Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Feeling down, depressed, or hopeless
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Trouble falling or staying asleep, or sleeping too much
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Feeling tired or having little energy
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Poor appetite or overeating
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Trouble concentrating on things, such as reading the newspaper or watching television
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
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 ususal
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Thoughts that you would be better of dead or hurting yourself in some way
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
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 ususal
Thoughts that you would be better of dead or hurting yourself in some way
Not at all
Row 0, Column 0
Several days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly every day
Row 0, Column 3
Not at all
Row 1, Column 0
Several days
Row 1, Column 1
More than half the days
Row 1, Column 2
Nearly every day
Row 1, Column 3
Not at all
Row 2, Column 0
Several days
Row 2, Column 1
More than half the days
Row 2, Column 2
Nearly every day
Row 2, Column 3
Not at all
Row 3, Column 0
Several days
Row 3, Column 1
More than half the days
Row 3, Column 2
Nearly every day
Row 3, Column 3
Not at all
Row 4, Column 0
Several days
Row 4, Column 1
More than half the days
Row 4, Column 2
Nearly every day
Row 4, Column 3
Not at all
Row 5, Column 0
Several days
Row 5, Column 1
More than half the days
Row 5, Column 2
Nearly every day
Row 5, Column 3
Not at all
Row 6, Column 0
Several days
Row 6, Column 1
More than half the days
Row 6, Column 2
Nearly every day
Row 6, Column 3
Not at all
Row 7, Column 0
Several days
Row 7, Column 1
More than half the days
Row 7, Column 2
Nearly every day
Row 7, Column 3
Not at all
Row 8, Column 0
Several days
Row 8, Column 1
More than half the days
Row 8, Column 2
Nearly every day
Row 8, Column 3
1 of 9
7
If you checked 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
8
Total Score (PHQ-9)
9
PHQ - 9: Depression severity scale

0-4: No depression
5-9: Mild depression
10-14: Moderate depression
15-19: Moderately severe depression
20-27: Severe depression
10
Over the last 2 weeks, how often have you been bothered by any of the following problems? * This field is required.
Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious, or on edge
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Not being able to stop or control worrying
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Worrying too much about different things
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Trouble relaxing
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Being so restless that it is hard to sit still
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Becoming easily annoyed or irritable
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Feeling afraid, as if something awful might happen
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid, as if something awful might happen
Not at all
Row 0, Column 0
Several days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly every day
Row 0, Column 3
Not at all
Row 1, Column 0
Several days
Row 1, Column 1
More than half the days
Row 1, Column 2
Nearly every day
Row 1, Column 3
Not at all
Row 2, Column 0
Several days
Row 2, Column 1
More than half the days
Row 2, Column 2
Nearly every day
Row 2, Column 3
Not at all
Row 3, Column 0
Several days
Row 3, Column 1
More than half the days
Row 3, Column 2
Nearly every day
Row 3, Column 3
Not at all
Row 4, Column 0
Several days
Row 4, Column 1
More than half the days
Row 4, Column 2
Nearly every day
Row 4, Column 3
Not at all
Row 5, Column 0
Several days
Row 5, Column 1
More than half the days
Row 5, Column 2
Nearly every day
Row 5, Column 3
Not at all
Row 6, Column 0
Several days
Row 6, Column 1
More than half the days
Row 6, Column 2
Nearly every day
Row 6, Column 3
1 of 7
11
If you checked 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
12
Total Score (GAD-7)
13
GAD-7: Scoring Anxiety Severity

This is calculated by assigning scores of 0, 1, 2, and 3 to the response categories, respectively, of "not at all," "several days," "more than half the days," and "nearly every day." GAD-7 total score for the seven items ranges from 0-21.

0-4: Minimal anxiety
5-9: Mild anxiety
10-14: Moderate anxiety
15-21: Severe anxiety
14
1. Choose the statement that best describes your health during the past week, including today.* This field is required.
I do not feel sad.
I feel sad.
I am sad all the time and I can't snap out of it.
I am so sad and unhappy that I can't stand it.
15
2. Choose the statement that best describes your health during the past week, including today.* This field is required.
I am not particularly discouraged about the future.
I feel discouraged about the future.
I feel I have nothing to look forward to.
I feel the future is hopeless and that things cannot improve.
16
3. Choose the statement that best describes your health during the past week, including today.* This field is required.
I do not feel like a failure.
I feel I have failed more than the average person.
As I look back on my life, all I can see is a lot of failures.
I feel I am a complete failure as a person.
17
4. Choose the statement that best describes your health during the past week, including today.* This field is required.
I get as much satisfaction out of things as I used to.
I don't enjoy things the way I used to.
I don't get real satisfaction out of anything anymore.
I am dissatisfied or bored with everything.
18
5. Choose the statement that best describes your health during the past week, including today.* This field is required.
I don't feel particularly guilty.
I feel guilty a good part of the time.
I feel quite guilty most of the time.
I feel guilty all of the time.
19
6. Choose the statement that best describes your health during the past week, including today.* This field is required.
I don't feel I am being punished.
I feel I may be punished.
I expect to be punished.
I feel I am being punished.
20
7. Choose the statement that best describes your health during the past week, including today.* This field is required.
I don't feel disappointed in myself.
I am disappointed in myself.
I am disgusted with myself.
I hate myself.
21
8. Choose the statement that best describes your health during the past week, including today.* This field is required.
I don't feel I am any worse than anybody else.
I am critical of myself for my weaknesses or mistakes.
I blame myself all the time for my faults.
I blame myself for everything bad that happens.
22
9. Choose the statement that best describes your health during the past week, including today.* This field is required.
I don't have any thoughts of killing myself.
I have thoughts of killing myself, but I would never carry them out.
I would like to kill myself.
I would kill myself if I had the chance.
23
10. Choose the statement that best describes your health during the past week, including today.* This field is required.
I don't cry any more than usual.
I cry more now than I used to.
I cry all the time now.
I used to be able to cry, but now I can't cry even though I want to.
24
11. Choose the statement that best describes your health during the past week, including today.* This field is required.
I am no more irritated by things than I ever was.
I am slightly more irritated now than usual.
I am quite annoyed or irritated a good deal of the time.
I feel irritated all the time.
25
12. Choose the statement that best describes your health during the past week, including today.* This field is required.
I have not lost interest in other people.
I am less interested in other people than I used to be.
I have lost most of my interest in other people.
I have lost all of my interest in other people.
26
13. Choose the statement that best describes your health during the past week, including today.* This field is required.
I make decisions about as well as I ever could.
I put off making decisions more than I used to.
I have greater difficulty in making decisions more than I used to.
I can't make decisions at all anymore.
27
14. Choose the statement that best describes your health during the past week, including today.* This field is required.
I don't feel that I look any worse than I used to.
I am worried that I am looking old or unattractive.
I feel there are permanent changes in my appearance that make me look unattractive.
I believe that I look ugly.
28
15. Choose the statement that best describes your health during the past week, including today.* This field is required.
I can work about as well as before.
It takes an extra effort to get started at doing something.
I have to push myself very hard to do anything.
I can't do any work at all.
29
16. Choose the statement that best describes your health during the past week, including today.* This field is required.
I can sleep as well as usual.
I don't sleep as well as I used to.
I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.
I wake up several hours earlier than I used to and cannot get back to sleep.
30
17. Choose the statement that best describes your health during the past week, including today.* This field is required.
I don't get more tired than usual.
I get tired more easily than I used to.
I get tired from doing almost anything.
I am too tired to do anything.
31
18. Choose the statement that best describes your health during the past week, including today.* This field is required.
My appetite is no worse than usual.
My appetite is not as good as it used to be.
My appetite is much worse now.
I have no appetite at all anymore.
32
19. Choose the statement that best describes your health during the past week, including today.* This field is required.
I haven't lost much weight, if any, lately.
I have lost more than 5 pounds.
I have lost more than 10 pounds.
I have lost more than 15 pounds.
33
20. Choose the statement that best describes your health during the past week, including today.* This field is required.
I am no more worried about my health than usual.
I am worried about physical problems like aches, pains, upset stomach, or constipation.
I am very worried about physical problems and it's hard to think of much else.
I am so worried about my physical problems that I cannot think of anything else.
34
21. Choose the statement that best describes your health during the past week, including today.* This field is required.
I have not noticed any recent change in my interest in sex.
I am less interested in sex than I used to be.
I have almost no interest in sex.
I have lost interest in sex completely.
35
Total Score (BDI)
36
BDI: Interpretation of Score - Levels of Depression

1-10: These ups and downs are considered norma
11-16: Mild mood disturbance
17-20: Borderline clinical depression
21-30: Moderate depression
31-40: Severe depression
37
The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. The PCL-5 along with a structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS-5) are the gold standard for diagnosing PTSD.

The PCL-5 has a variety of purposes, including:

Monitoring symptom change during and after treatment
Screening individuals for PTSD
Making a provisional PTSD diagnosis

It takes approximately 5-10 minutes to complete. Upon submission, your clinician will review and score your answers for the most accurate interpretation. You may discuss the results at your next visit.
38
Below is a list of problems that people sometimes have in response to a very stressful experience. Keeping your worst event in mind, please read each problem carefully and then select how much you have been bothered by that problem in the past month.
39
Please explain your most stressful event that is bothering you at least once a month.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
40
In the past month, how much were you bothered by:* This field is required.
Not at all
Several days
More than half the days
Nearly every day
Repeated, disturbing, and unwanted memories of the stressful experience?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Repeated, disturbing dreams of the stressful experience?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Feeling very upset when something reminded you of the stressful experience?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Avoiding memories, thoughts, or feelings related to the stressful experience?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Trouble remembering important parts of the stressful experience?
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
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)?
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Blaming yourself or someone else for the stressful experience or what happened after it?
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Having strong negative feelings such as fear, horror, anger, guilt, or shame?
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Loss of interest in activities that you used to enjoy?
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Feeling distant or cut off from other people?
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Irritable behavior, angry outbursts, or acting aggressively?
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Taking too many risks or doing things that could cause you harm?
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Row 15, Column 3
Being “super alert” or watchful or on guard?
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Feeling jumpy or easily startled?
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Row 17, Column 3
Having difficulty concentrating?
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Row 18, Column 3
Trouble falling or staying asleep?
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
Row 19, Column 3
Repeated, disturbing, and unwanted memories of the stressful experience?
Repeated, disturbing dreams of the stressful experience?
Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
Feeling very upset when something reminded you of the stressful experience?
Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
Avoiding memories, thoughts, or feelings related to the stressful experience?
Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
Trouble remembering important parts of the stressful experience?
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)?
Blaming yourself or someone else for the stressful experience or what happened after it?
Having strong negative feelings such as fear, horror, anger, guilt, or shame?
Loss of interest in activities that you used to enjoy?
Feeling distant or cut off from other people?
Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
Irritable behavior, angry outbursts, or acting aggressively?
Taking too many risks or doing things that could cause you harm?
Being “super alert” or watchful or on guard?
Feeling jumpy or easily startled?
Having difficulty concentrating?
Trouble falling or staying asleep?
Not at all
Row 0, Column 0
Several days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly every day
Row 0, Column 3
Not at all
Row 1, Column 0
Several days
Row 1, Column 1
More than half the days
Row 1, Column 2
Nearly every day
Row 1, Column 3
Not at all
Row 2, Column 0
Several days
Row 2, Column 1
More than half the days
Row 2, Column 2
Nearly every day
Row 2, Column 3
Not at all
Row 3, Column 0
Several days
Row 3, Column 1
More than half the days
Row 3, Column 2
Nearly every day
Row 3, Column 3
Not at all
Row 4, Column 0
Several days
Row 4, Column 1
More than half the days
Row 4, Column 2
Nearly every day
Row 4, Column 3
Not at all
Row 5, Column 0
Several days
Row 5, Column 1
More than half the days
Row 5, Column 2
Nearly every day
Row 5, Column 3
Not at all
Row 6, Column 0
Several days
Row 6, Column 1
More than half the days
Row 6, Column 2
Nearly every day
Row 6, Column 3
Not at all
Row 7, Column 0
Several days
Row 7, Column 1
More than half the days
Row 7, Column 2
Nearly every day
Row 7, Column 3
Not at all
Row 8, Column 0
Several days
Row 8, Column 1
More than half the days
Row 8, Column 2
Nearly every day
Row 8, Column 3
Not at all
Row 9, Column 0
Several days
Row 9, Column 1
More than half the days
Row 9, Column 2
Nearly every day
Row 9, Column 3
Not at all
Row 10, Column 0
Several days
Row 10, Column 1
More than half the days
Row 10, Column 2
Nearly every day
Row 10, Column 3
Not at all
Row 11, Column 0
Several days
Row 11, Column 1
More than half the days
Row 11, Column 2
Nearly every day
Row 11, Column 3
Not at all
Row 12, Column 0
Several days
Row 12, Column 1
More than half the days
Row 12, Column 2
Nearly every day
Row 12, Column 3
Not at all
Row 13, Column 0
Several days
Row 13, Column 1
More than half the days
Row 13, Column 2
Nearly every day
Row 13, Column 3
Not at all
Row 14, Column 0
Several days
Row 14, Column 1
More than half the days
Row 14, Column 2
Nearly every day
Row 14, Column 3
Not at all
Row 15, Column 0
Several days
Row 15, Column 1
More than half the days
Row 15, Column 2
Nearly every day
Row 15, Column 3
Not at all
Row 16, Column 0
Several days
Row 16, Column 1
More than half the days
Row 16, Column 2
Nearly every day
Row 16, Column 3
Not at all
Row 17, Column 0
Several days
Row 17, Column 1
More than half the days
Row 17, Column 2
Nearly every day
Row 17, Column 3
Not at all
Row 18, Column 0
Several days
Row 18, Column 1
More than half the days
Row 18, Column 2
Nearly every day
Row 18, Column 3
Not at all
Row 19, Column 0
Several days
Row 19, Column 1
More than half the days
Row 19, Column 2
Nearly every day
Row 19, Column 3
1 of 20
41
Total Score (PCL-5)
42
PCL-5: Provisional diagnosis of PTSD

Criterion A of the DSM-5, plus
Criterion B (Intrusion)—at least 1 (Questions 1-5)
Criterion C (Avoidance)—at least 1 (Questions 6-7)
Criterion D (Negative alterations in cognition and mood)—at least 2 (Questions 8-14)
Criterion E (Hyperarousal)—at least 2 (Questions 15-20)

Lower than 31-33: The patient either has subthreshold symptoms of PTSD or does NOT meet the criteria for PTSD.
Higher than 31-33: Patient may benefit from PTSD treatment.
Should be Empty: