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PATIENT HEALTH QUESTIONNAIRE (PHQ-9)
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Over the past 2 weeks, how often have you been bothered by any of the following problems?
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Little interest or pleasure in doing things
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Feeling down, depressed, or hopeless
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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 that you're a failure or have let yourself or your family down
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Trouble concentrating on things, such as reading the newspaper or watching TV
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Moving or speaking slowly that other people could have noticed. Or the opposite, being so fidgety or restless?
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Thoughts you would be better off dead or of hurting yourself in some way
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How difficult have those problems made it for you to do your work, take care of things at home, or get along with other people?
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GENERALIZED ANXIETY DISORDER QUESTIONNAIRE (GAD-7)
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Over the past 2 weeks, how often have you been bothered by any of the following problems?
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Feeling anxious, nervous, or on edge
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Not being able to stop or control worrying
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Worrying too much about different things
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Trouble relaxing
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Being so restless it is hard to sit still
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Becoming easily annoyed or irritable
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Feeling afraid as if something awful is going to happen
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How difficult have those problems made it for you to do your work, take care of things at home, or get along with other people?
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BRIEF SAFETY SCREEN
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In the past few weeks, have you wished you were dead or wish that you could go to sleep and not wake up?
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In the past few weeks, have you felt that either you or your family would be better off if you were dead?
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In the past few weeks, have you been having thoughts about killing yourself?
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In the past few weeks, have you experienced any of the following feelings? (Please check all that apply)
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NATIONAL SUICIDE PREVENTION LIFELINE: 1-800-273-8255
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Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist
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Rate yourself on each of the criteria that best describes how you have felt and conducted yourself over the past 6 months.
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How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
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How often do you have difficulty getting things in order when you have to do a task that requires organization?
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How often do you have problems remembering appointments or obligations?
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When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
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How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
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How often do you feel overly active and compelled to do things, like you were driven by a motor?
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How often do you make careless mistakes when you have to work on a boring or difficult project?
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How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
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How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
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How often do you misplace or have difficulty finding things at home or at work?
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How often are you distracted by activity or noise around you?
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How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
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How often do you feel restless or fidgety?
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How often do you have difficulty unwinding and relaxing when you have time to yourself?
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How often do you find yourself talking too much when you are in social situations?
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When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to?
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How often do you have difficulty waiting your turn in situations when turn taking is required?
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How often do you interrupt others when they are busy?
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AUTHORIZATION FOR RELEASE OF INFORMATION
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I hereby authorize Healthy Regards Psychiatry and its staff to (check all that apply):
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Name:
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Address:
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Telephone number:
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