SET-PAD Patient Forms
Date
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Name
First Name
Last Name
Patient Health Questionnaire
Over the last 2 weeks, how often have you been bothered by any of the following problems?
*
Rows
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Little interest or pleasure in doing things.
Feeling down, depressed, or hopeless.
Trouble falling/staying asleep, 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 TV.
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 more than usual.
Thoughts that you would be better off dead or of hurting yourself in some way.
Total Score
If you checked off any problem on this questionnaire so far, 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
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VascuQoL-6
Because of the poor circulation in my legs, the range of activities that I would have liked to do in the past two weeks has been ....
1 Severely limited - most activities not done
2 Moderately limited - several activities not done
3 Very slightly limited - very few activities not done
4 Not limited at all - have done all the activities that I wanted to
During the past two weeks, my legs felt tired or weak...
1 All of the time
2 Some of the time
3 A little of the time
4 None of the time
During the past two weeks, because of the poor circulation in my legs, my ability to walk has been ....
1 Totally limited, couldn't walk at all
2 Very limited
3 A little limited
4 Not at all limited
During the past two weeks, I have been concerned about having poor circulation in my legs. ...
1 All of the time
2 Some of the time
3 A little of the time
4 None of the time
During the past two weeks, because of the poor circulation in my legs, my ability to participate in social activities has been ....
1 Totally limited, couldn't socialize at all
2 Very limited
3 A little limited
4 Not at all limited
During the past two weeks, when I have had pain in the leg (or foot) it has given me ...
1 A great deal of discomfort or distress
2 A moderate amount of discomfort or distress
3 Very little discomfort or distress
4 No discomfort or distress
Type a question
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