Rural Harvest of Health: Feeding Families, Fighting Chronic Disease
November 14, 2026
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex
*
Please Select
Female
Male
Intersex
Prefer not to answer
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific
White
More than one race
Prefer not to answer
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
DEPRESSION SCREEN (PHQ-9)
Over the last 2 weeks, how often have you been bothered by any of the following problems? (Each question scored 0 to 3):
1. Little interest or pleasure in doing things?
*
(0) Not at all
(1) Several days
(2) More than half the days
(3) Nearly every day
2. Feeling down, depressed, or hopeless?
*
(0) Not at all
(1) Several days
(2) More than half the days
(3) Nearly every day
3. Trouble falling or staying asleep, or sleeping too much?
*
(0) Not at all
(1) Several days
(2) More than half the days
(3) Nearly every day
4. Feeling tired or having little energy?
*
(0) Not at all
(1) Several days
(2) More than half the days
(3) Nearly every day
5. Poor appetite or over eating?
*
(0) Not at all
(1) Several days
(2) More than half the days
(3) Nearly every day
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down?
*
(0) Not at all
(1) Several days
(2) More than half the days
(3) Nearly every day
7. Trouble concentrating on things such as reading the newspaper or watching television?
*
(0) Not at all
(1) Several days
(2) More than half the days
(3) Nearly every day
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?
*
(0) Not at all
(1) Several days
(2) More than half the days
(3) Nearly every day
9. Thoughts that you would be better off dead or hurting yourself in some way?
*
(0) Not at all
(1) Several days
(2) More than half the days
(3) Nearly every day
Total Score:
0-4 None to minimal
5-9 Mild
10-14 Moderate
15-19 Moderately Severe
20-27 Severe
Back
Next
DAST 10 Screening Tool
The types of drugs covered may include cannabis (marijuana or hashish), solvents (such as paint thinner), tranquilizers (such as Valium), barbiturates, cocaine, heroin, and the following:Opioids: fentanyl, oxycodone, hydrocodone, or tramadol taken outside prescription directionsBenzodiazepines: alprazolam (Xanax) or clonazepam (Klonopin) misusedStimulants: methamphetamine, or Adderall or Vyvanse misusedSynthetic cannabinoids and high-potency cannabis: K2 or Spice, or high-potency THC vapes or ediblesHallucinogens and dissociatives: psilocybin, MDMA, PCP, or ketamineOther medicines misused: gabapentin, or high doses of over-the-counter products such as dextromethorphan cough syrup or loperamideInhalants: nitrous oxide (“whippets”) or aerosolsThese questions do not include alcoholic beverages or tobacco. Please answer every question. If you have difficulty answering a statement, choose the response that is mostly right for you.
How often have you used these drugs?
*
Never
Monthly or less
Weekly
Daily or almost daily
Have you used drugs other than those required for medical reasons?
*
Yes
No
Do you abuse more than one drug at a time?
*
Yes
No
Are you unable to stop using drugs when you want to?
*
Yes
No
Have you ever had blackouts or flashbacks as a result of drug use?
*
Yes
No
Do you ever feel bad or guilty about your drug use?
*
Yes
No
Does your partner/spouse (or parents) ever complain about your involvement with drugs?
*
Yes
No
Have you neglected your family or loved ones because of your use of drugs?
*
Yes
No
Have you engaged in illegal activities in order to obtain drugs?
*
Yes
No
Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
*
Yes
No
Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?
*
Yes
No
Have you ever injected drugs?
*
Never
Yes, in the past 90 days
Yes, more than 90 days
Have you ever been in treatment for substance abuse?
*
Never
Currently
In the past
Scoring: Score 1 point for each question answered “Yes,” except for question 3 for which a “No” receives 1 point.
0 No problems reported; no action required
1‐2 Low level; Watch, re‐assess @ later date
3‐5 Moderate level; Further Investigation
6‐8 Substantial level; Intensive assessment
9‐10 Severe level; Intensive assessment
Anxiety Severity Questionnaire (GAD-7)
Each answer will be scored on a scale from 0-3
1. Feeling nervous, anxious or on edge?
*
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
2. Not being able to stop or control worrying?
*
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
3. Worrying too much about different things?
*
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
4. Trouble relaxing?
*
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
5. Being so restless that it is hard to sit still?
*
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
6. Becoming easily annoyed or irritable?
*
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
7. Feeling afraid as if something awful might happen
*
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Total Score:
0-4: Minimal Anxiety
5-9: Mild Anxiety
10-14: Moderate Anxiety
> 15: Severe Anxiety
Signature
Submit
Submit
Should be Empty: