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ALL PATIENTS: Please complete this form
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no more than 24 hours prior to your appointment.
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Have you recently had any of these symptoms?
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If yes, you must select all that apply
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General Symptoms
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General Symptoms
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Comments
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HEENT
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HEENT
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Comments
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Cardiovascular
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Cardiovascular
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comments
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Respiratory
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Respiratory
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comments
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GI
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GI
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comments
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Skin
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Skin
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comments
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Urinary
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Urinary
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comments
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Sexual Health- Females
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Sexual Health Females
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Sexual Health- Males
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Sexual History- Males
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comments
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Endocrine
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Endocrine
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comments
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Neurological
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Neurological
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comments
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Musculoskeletal
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Musculoskeletal
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comments
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I consume caffeine, alcohol, nicotine, etc
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Substance Use
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1oz spirits, 12oz beer, or 4.5oz wine is 1 drink
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Highest number of drinks in one day
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Highest number of drinks in one week
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Caffeine use
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Nicotine use
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Marijuana Use
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Other substance use
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Comments
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I'm feeling pretty well lately.
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Please answer based on the last 2 weeks.
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WHO5 Wellbeing Index
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I have felt cheerful and in good spirits
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I woke up feeling fresh and rested
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Daily life has been filled w/ interesting things
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I have felt calm and relaxed
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I have felt active and vigorous
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Score
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Anxiety has been an issue for me.
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GAD 7
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In the past 2 weeks, I've been bothered by
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Feeling nervous, anxious, or on edge
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Trouble relaxing
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Not being able to stop/control worrying
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Being so restless that it is hard to sit still
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Worrying too much about different things
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Becoming easily annoyed or irritable
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Feel afraid, as if something awful might happen
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Score
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Low mood has been an issue for me.
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WHO Major Depression Inventory
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Please answer based on the past two weeks
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Have you felt in low spirits or sad?
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Have you lost interest in your daily activities?
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Have you felt lacking in energy and strength?
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Have you felt less self confident?
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Have you had a bad conscience/feelings of guilt?
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Have you felt that life wasn't worth living?
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Have you had difficulty in concentrating?
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Have you felt very restless?
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Have you felt subdued or slowed down?
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Have you had trouble sleeping at night?
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Have you suffered from reduced appetite?
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Have you suffered from increased appetite?
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Score
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I have, or think I have ADHD
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1. Do you have trouble wrapping up final project
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details, once the challenging part is done?
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2. Do you have trouble getting things in order
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when you have a task requiring organization?
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3. Do you have problems remembering appointments
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and obligations?
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4. Do you avoid or delay getting started when
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you have a task that requires a lot of thought?
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5. Do you fidget or squirm with your hands/feet
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when you have to sit down for a long time?
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6. Do you feel overly active & compelled to do
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things, like you are driven by a motor?
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Part A Score
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7. How often do you make careless mistakes when
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you have to work on a boring/difficult project?
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8. Do you have trouble keeping your attention
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when you are doing boring or repetitive work?
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9. Do you have difficulty concentrating on what
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people say to you, even when they are speaking
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directly to you?
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10. How often do you misplace or have difficulty
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finding things at home or at work?
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11. Are you distracted by activity or noise
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around you?
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12. Do you leave your seat in meetings or other
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situations when you're expected to stay seated?
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13. How often do you feel restless or fidgety?
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14. How often do you have difficulty unwinding
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and relaxing when you have time to yourself?
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15. How often do you find yourself talking too
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much when you are in social situations?
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16. In conversation, how often do you find
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finishing the sentences of the people you are
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talking to, before they can finish themselves?
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17. Do you have difficulty waiting your turn in
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situations when turn taking is required?
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18. Do you interrupt others when they are busy?
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Part B Score
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Safety
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I feel safe at home and in my relationships.
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I own or have access to firearms
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I drive/ride in cars with an intoxicated driver.
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Comments
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