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SCRENING TOOLS
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Assessment Tools
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Over two scales done?
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Person Assessing
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Results Discussed with Patient
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PHQ-9
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Over the last 2 weeks, how often have you been bothered by
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1. Little interest or pleasure doing things
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2. Feeling down / depressed / hopeless
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3. Trouble falling or staying asleep, or sleeping too much
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4. Feeling tired and having little energy
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5. Poor appetite or over eating
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6. Feeling bad about yourself/feeling a failure/feeling you have let people down:
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7. Trouble concentrating on things, such as reading the newspaper/watching television
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8. Moving/Speaking so slow that other people could have noticed/the opposite
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9. Thoughts that you would be better off dead or of hurting yourself in someway
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PHQ9 Scoring
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Comments
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GAD-7
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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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GAD-7 Scoring
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Comments
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CAGE
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1. Ever felt the need to cut down on drinking/drug use?
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2. Have people annoyed you by criticizing your drinking or drug use?
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3. Have you felt bad or guilty about your drinking or drug use?
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4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
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CAGE Scoring
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Suicide Risk Assessment
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Have these symptoms of depression led you to think you might be better off dead? - if No, Stop
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This past week, have you had any thoughts that life is not worth living or that you would be better off dead?
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What about thoughts about hurting or even killing yourself? - if No, Stop.
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What have you thought about? Have you actually done anything to hurt yourself?
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Major Risk Factors
• • •
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Other Risk Factors:
• • •
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Assessment of Suicide Risk and Action Plan
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Comments
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Elder Abuse Screening
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Q1-5 asked of patient Q6 answered by provider. Within the last year:
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Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?
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Has anyone prevented you from getting food, clothes, meds, glasses, hearing aids or medical care, or from being with people?
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Have you been upset because someone talked to you in a way that made you feel shamed or threatened?
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Has anyone tried to force you to sign papers or to use your money against your will?
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Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?
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Doctor: poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, inappropriate clothing, or med issues
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Elder Abuse Scoring
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Comments
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HAM-D
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*DEPRESSED MOOD (Gloomy, pessimistic, sad, weep)
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*FEELINGS OF GUILT
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*SUICIDE
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INSOMNIA - Initial
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INSOMNIA - Middle
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INSOMNIA - Delayed
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WORK AND INTERESTS
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RETARDATION
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AGITATION
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ANXIETY - PSYCHIC
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ANXIETY - SOMATIC
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Somatic symptom-gastrointestinal
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Somatic symptoms-general
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GENITAL SYMPTOMS
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Hypochondriasis
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WEIGHT LOSS
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INSIGHT
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DIURNAL VARIATION
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Depersonalization &Derealization
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PARANOID SYMPTOMS
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OBSESSIONAL SYMPTOMS
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Total item 1-17
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Comments
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