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

onpatient Reasons For Visit Medical Form

Nurse Practitioner

SMP

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Published: Sept. 25, 2023, 6:22 p.m.
Doctor: Dr. History Physical
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328 Gibraltar Dr
Sunnyvale, CA 94089

Call us: (844) 569-8628

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