All patients, both new and established, should answer all questions in this section prior to their appointment.
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WHO5 Wellbeing Index
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Please answer based on how you have felt during the last 2 weeks.
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I have felt cheerful and in good spirits
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I woke up feeling fresh and rested
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Daily life has been filled w/ interesting things
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I have felt calm and relaxed
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I have felt active and vigorous
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Score
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GAD 7 Anxiety Scale
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In the past 2 weeks, I've been bothered by:
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Feeling nervous, anxious, or on edge
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Trouble relaxing
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Not being able to stop/control worrying
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Being so restless that it is hard to sit still
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Worrying too much about different things
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Becoming easily annoyed or irritable
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Feel afraid, as if something awful might happen
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Score
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WHO Major Depression Inventory
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Please answer based on how you have felt during the last 2 weeks.
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1) Have you felt in low spirits or sad?
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2) Have you lost interest in your daily activities?
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3) Have you felt lacking in energy and strength?
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4) Have you felt less self confident?
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5) Have you had a bad conscience/feelings of guilt?
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6) Have you felt that life wasn't worth living?
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7) Have you had difficulty in concentrating?
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8a) Have you felt very restless?
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8b) Have you felt subdued or slowed down?
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9) Have you had trouble sleeping at night?
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10a) Have you suffered from reduced appetite?
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10b) Have you suffered from increased appetite?
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Score
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I have, or think I have ADHD
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ASRS v 1.1
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1. 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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2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
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3. How often do you have problems remembering appointments or obligations?
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4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
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5. 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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6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
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Part A Score
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7. How often do you make careless mistakes when you have to work on a boring or difficult project?
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8. 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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10. How often do you misplace or have difficulty finding things at home or at work?
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11. 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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13. How often do you feel restless or fidgety?
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14. 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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16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are
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talking to, before they can finish them themselves?
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17. How often do you have difficulty waiting your turn in situations when turn taking is required?
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18. How often do you interrupt others when they are busy?
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Part B Score
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Substance Use
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1oz spirits, 12oz beer, or 4.5oz wine is 1 drink
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How often do you have a drink containing alcohol?
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How many standard drinks containing alcohol do you have on a typical day?
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How often do you have 6 or more drinks on one occasion?
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Comments
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Caffeine use
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Comments
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Marijuana Use
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Comments
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Nicotine use
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Comments
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Other substance use
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Comments
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Safety
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I feel safe at home and in my relationships.
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I own or have access to firearms
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I drive/ride in cars with an intoxicated driver.
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Comments
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