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Where did you find us?
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Who referred you?
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Psychiatric and Medical History
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Past Psychiatric Medications
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Do you use online scheduling?
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Want access to online portal?
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Anything special we need to know
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DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult
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If this questionnaire is completed by an informant, what is your relationship with the individual?
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In a typical week, approximately how much time do you spend with the individual? (hours/week)
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During the past TWO (2) WEEKS, how much (or how often)
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have you been bothered by the following problems?
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I
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1. Little interest or pleasure in doing things?
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2. Feeling down, depressed, or hopeless?
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Highest Domain Score (clinician)
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II
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3. Feeling more irritated, grouchy, or angry than usual?
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Highest Domain Score (clinician)
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III
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4. Sleeping less than usual, but still have a lot of energy?
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5. Starting lots more projects than usual or doing more risky things than usual?
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Highest Domain Score (clinician)
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IV
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6. Feeling nervous, anxious, frightened, worried, or on edge?
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7. Feeling panic or being frightened?
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8. Avoiding situations that make you anxious?
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Highest Domain Score (clinician)
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V
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9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?
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10. Feeling that your illnesses are not being taken seriously enough?
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Highest Domain Score (clinician)
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VI
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11. Thoughts of actually hurting yourself?
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Highest Domain Score (clinician)
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VII
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12. Hearing things other people couldn’t hear, such as voices even when no one was around?
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13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
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Highest Domain Score (clinician)
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VIII
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14. Problems with sleep that affected your sleep quality over all?
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Highest Domain Score (clinician)
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IX
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15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?
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Highest Domain Score (clinician)
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X
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16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?
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17. Feeling driven to perform certain behaviors or mental acts over and over again?
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Highest Domain Score (clinician)
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XI
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18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
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Highest Domain Score (clinician)
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XII
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19. Not knowing who you really are or what you want out of life?
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20. Not feeling close to other people or enjoying your relationships with them?
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Highest Domain Score (clinician)
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XIII
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21. Drinking at least 4 drinks of any kind of alcohol in a single day?
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22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
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23. Using any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer th
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Highest Domain Score (clinician)
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Center for Epidemiological Studies Depression Scale for Children (CES-DC) - For patients under the age of 14
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Please read the instructions here before updating the info below
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DURING THE PAST WEEK
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1. I was bothered by things that usually don’t bother me
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2. I did not feel like eating, I wasn’t very hungry
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3. I wasn’t able to feel happy, even when my family or friends tried to help me feel better
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4. I felt like I was just as good as other kids
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5. I felt like I couldn’t pay attention to what I was doing
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6. I felt down and unhappy
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7. I felt like I was too tired to do things
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8. I felt like something good was going to happen
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9. I felt like things I did before didn’t work out right
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10. I felt scared
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11. I didn’t sleep as well as I usually sleep
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12. I was happy
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13. I was more quiet than usual
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14. I felt lonely, like I didn’t have any friends
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15. I felt like kids I know were not friendly or that they didn’t want to be with me
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16. I had a good time
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17. I felt like crying
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18. I felt sad
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19. I felt people didn’t like me
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20. It was hard to get started doing things
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Travel / Exposure History
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Has the patient traveled anywhere outside of {{INSERT YOUR STATE}} in the last 30 days?
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Where?
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Has the patient traveled to China, Iran, Italy, Japan, or South Korea in the last 14 days?
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In the 14 days prior to illness onset, did the patient have any of the following exposures?
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Comments
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