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Please click the button if the question applies to you.
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Do you have frequent mood swings and irritability?
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MDQ Q1
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Good & Hyper Feelings
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Irritability
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Self Confidence
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Sleep Loss
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Talkativeness / Talking Speed
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Racing Thoughts
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Distractability
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Increased Sociability
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Increased Energy Levels
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increased Activity Level
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Increased Libido
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Money Over-spending
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Risky Behavior
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MDQ Q2
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Symptom Timing
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MDQ Q3
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Symptoms Problem Level
• • •
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MDQ Q4
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Family Hx Bipolar
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MDQ Q5
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Past Dx of Bipolar
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Have you ever experienced or been exposed to any type of traumatic event/stress?
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PTSD CHECKLIST:
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1. Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?
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2. Repeated, disturbing dreams of a stressful experience from the past?
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3. Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)?
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4. Feeling very upset when something reminded you of a stressful experience from the past?
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5. Having physical reactions when something reminded you of a stressful experience from the past?
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6. Avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it?
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7. Avoid activities or situations because they remind you of a stressful experience from the past?
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8. Trouble remembering important parts of a stressful experience from the past?
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9. Loss of interest in things that you used to enjoy?
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10. Feeling distant or cut off from other people?
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11. Feeling emotionally numb or being unable to have loving feelings for those close to you?
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12. Feeling as if your future will somehow be cut short?
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13. Trouble falling or staying asleep?
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14. Feeling irritable or having angry outbursts?
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15. Having difficulty concentrating?
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16. Being `super alert` or watchful on guard?
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17. Feeling jumpy or easily startled?
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Do you now or have you ever felt depressed?
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PHQ9 Depression Screening Form
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problems in the past two weeks:
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Loss of Interest?
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Feeling down, depressed or hopeless?
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Trouble Sleeping?
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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 oneself?
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Trouble Concentrating?
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Feeling slowed down or fidgety & restless?
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Wanting to die or self harm?
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Difficulty of these problems?
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Have you ever used any type of illegal drug, used marijuana, or drank alcohol?
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DAST-10: In the past 12 months ...
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1. Have you used drugs other than those required for medical reasons?
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2. Do you abuse more than one drug at a time?
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3. Are you unable to stop abusing drugs when you want to?
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4. Have you ever had blackouts or flashbacks as a result of drug use?
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5. Do you ever feel bad or guilty about your drug use?
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6. Does your spouse (or parents) ever complain about your involvement with drugs?
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7. Have you neglected your family because of your use of drugs?
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8. Have you engaged in illegal activities in order to obtain drugs?
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9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
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10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?
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Do you ever have problems with overeating or impulsive eating?
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Binge Eating Screening
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During the last 3 months, did you have any episodes of excessive overeating
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Distressed about overeating?
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Last 3 mo...no control over eating?
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Last 3 mo...continue to eat when not hungry? Stress eating?
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Last 3 mo...Embarrassed by how much you ate?
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Last 3 mo...Feel Disgusted or guilty after eating?
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Last 3 mo...Make yourself vomit to control weight?
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Do you have a problem with feeling too sleepy during the day?
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Do you ever doze off Sitting and Reading?
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Do you frequently fall asleep Watching TV?
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Do you fall asleep when Sitting Inactive in a Public Place?
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Do you fall asleep as a passenger in a car for an hour and no break?
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Do you lay down to rest in the afternoon when you can?
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Do you doze off when Sitting and Talking to Someone?
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Do you doze off when Sitting quietly after lunch without alcohol?
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Do you doze off when In a car while stopped for few mins in traffic?
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Do you have problems sleeping?
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Do you wake up feeling heavy or tired?
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Do you feel more tired during the day although you sleep enough?
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If you wake up in the middle of the night, do you have trouble going back to sleep?
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Do you use to have dinner late?
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Do you often wake up dehydrated?
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Do you twitch or jerk your legs or arms during sleep?
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Do you think stress or anxiety might affect your sleep?
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How do you wake up in the morning?
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How would you assess the quality of your sleep?
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How long it takes you to fall asleep?
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Which do you consider is your sleep problem?
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How many hours do you sleep on average?
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Are your perceived sleep problems impairing your daily activities?
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Do you have other breathing problems that prevent you from deep sleep?
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Do you consume caffeinated beverages in the afternoon?
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Do you move a lot during sleep?
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Do you wake up during your sleep?
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Do you experience nightmares?
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Do you or your partner snore?
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Do you sleep in a properly aired room?
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Do you consider you have comfortable sleep conditions?
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Do you take baths before you go to sleep?
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Do you consider you have a stable sleep pattern?
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Do you undergo any treatment that could affect your sleep?
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Age 0-17
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Please select the ALL life events that have occurred in the past year:
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Holmes and Rahe Stress Scale Score:
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Parents please complete the next few questions about your child.
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Does not pay attention to details or makes careless mistakes with, for example, homework
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Has difficulty keeping attention to what needs to be done
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Does not seem to listen when spoken to directly
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Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
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Has difficulty organizing tasks and activities
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Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
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Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
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Is easily distracted by noises or other stimuli
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Is forgetful in daily activities
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Fidgets with hands or feet or squirms in seat
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Leaves seat when remaining seated is expected
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Runs about or climbs too much when remaining seated is expected
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Has difficulty playing or beginning quiet play activities
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Is “on the go” or often acts as if “driven by a motor”
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Talks too much
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Blurts out answers before questions have been completed
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Has difficulty waiting his or her turn
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Interrupts or intrudes in on others’ conversations and/or activities
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Argues with adults
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Loses temper
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Actively defies or refuses to go along with adults’ requests or rules
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Blames others for his or her mistakes or misbehaviors
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Is touchy or easily annoyed by others
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Is spiteful and wants to get even
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Starts physical fights
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Lies to get out of trouble or to avoid obligations (i.e. “cons” others)
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Is truant from school (skips school) without permission
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Is physically cruel to people
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Has stolen things that have value
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Deliberately destroys others’ property
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Has used a weapon that can cause serious harm (bat, knife, brick, gun)
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Is physically cruel to animals
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Has deliberately set fires to cause damage
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Has broken into someone else’s home, business, or car
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Has stayed out at night without permission
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Has run away from home overnight
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Has forced someone into sexual activity
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Is fearful, anxious, or worried
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Is afraid to try new things for fear of making mistakes
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Feels worthless or inferior
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Blames self for problems, feels guilty
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Feels lonely, unwanted, or unloved; complains that “no one loves him or her”
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Is sad, unhappy, or depressed
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Is self-conscious or easily embarrassed
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Overall school performance
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Reading
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Writing
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Math
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Relationship with Parents
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Relationship with siblings
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Relationship with peers
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Participation in organized activities (e.g. teams)
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Age 18 and above
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Please select the ALL life events that have occurred in the past year:
• • •
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Holmes and Rahe Stress Scale Score:
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Do you drink alcohol?
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Have you felt like you should cut down?
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Ever felt bad or guilty about drinking?
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Have people annoyed you by criticizing your drinking?
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Drink to cure hangover/steady nerves?
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Do you have problems with attention, focus, or hyperactive behaviors?
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Indicate which answer 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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PART B 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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9 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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12 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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15 How often do you find yourself talking too much when you are in social situations?
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How often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
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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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Do you ever feel nervous or anxious?
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Over the last 2 weeks, how often have you been bothered by the following problems?
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1. Feeling nervous, anxious or on edge
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2. Not being able to stop or control worrying
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3. Worrying too much about different things
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4. Trouble relaxing
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5. Being so restless that it is hard to sit still
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6. Becoming easily annoyed or irritable
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7. Feeling afraid as if something awful might happen
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Have you been referred here by Pain Clinic for evaluation?
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Satisfaction With Life Scale
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1. In most ways my life is close to my ideal.
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2. The conditions of my life are excellent.
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3. I am satisfied with my life.
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4. So far I have gotten the important things I want in life.
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5. If I could live my life over, I would change almost nothing.
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General Self Efficacy Scale
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1. I can always manage to solve difficult problems if I try hard enough.
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2. If someone opposes me, I can find the means and ways to get what I want.
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3. It is easy for me to stick to my aims and accomplish my goals.
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4. I am confident that I could deal efficiently with unexpected events.
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5. Thanks to my resourcefulness, I know how to handle unforeseen situations.
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6. I can solve most problems if I invest the necessary effort.
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7. I can remain calm when facing difficulties because I can rely on my coping abilities.
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8. When I am confronted with a problem, I can usually find several solutions.
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9. If I am in trouble, I can usually think of a solution.
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10. I can usually handle whatever comes my way.
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Oswestry Disability Index (ODI) For Low Back Pain
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1. Pain Intensity
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2. Personal Care
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3. Lifting
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4. Walking
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5. Sitting
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6. Standing
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7. Sleeping
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8. Sex Life
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9. Social Life
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10. Travelling:
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