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Medical patients
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Wellness / Prevention Visit
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Problem / Issue Visit
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Musculoskeletal pain
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Cold/flu Symptoms
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Other - please explain
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Aesthetic patients
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I am interested in the following:
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I currently use or have used the following:
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Life Satisfaction Survey: Please answer the following 2 questions
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Over the LAST 2 WEEKS, how often have you been bothered by:
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Little Interest or Pleasure in Doing Things:
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Feeling down, depressed or hopeless?
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Score of 3 or more from the above questions? Please continue:
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Trouble falling asleep, staying asleep, or sleeping too much?
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Feeling tired or having little energy?
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Poor appetite or overeating?
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Feeling bad about yourself - or failure, or let yourself of your family down?
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Trouble concentrating on things, such as reading, watching TV?
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Moving or speaking so slowly / or fidgety & restlessly, that others have noticed?
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Thoughts of harming yourself in some way, or that you would be better off dead?
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