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PHQ-9
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Over the last 2 weeks, how often have you been bothered by any of the following problems?
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1. Little interest or pleasure in doing things
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2. Feeling down, depressed or hopeless
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3. Trouble falling or staying asleep, or sleeping too much
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4. Feeling tired or having little energy
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5. Poor appetite or overeating
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6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
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7. Trouble concentrating on things, such as reading the newspaper or watching television
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8. Moving or speaking so slowly that other people could have noticed? Or the opposite - being noticably fidgety or restless
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9. Thoughts that you would be better off dead or of hurting yourself in some way
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Please add up total number based on responses:
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Difficulty of these problems to work, socialize, and take care of things at home?
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GAD-7
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Over the last two 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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Please add up total number based on responses:
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If you checked any problems, how difficult have they made your everday life
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C-SSRS
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Since last visit, or in the past month (if first visit):
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1. Have you wished you were dead or wished you could go to sleep and not wake up?
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2. Have you actually had any thoughts of killing yourself?
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If you answered No to question 2, skip directly to question 6
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3. Have you thought about how you might do this? (For example, “I thought about taking an overdose but I never worked out the details about when, where, and how I would do that and I would never act on these thoughts.”)
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4. Have you had any intention of acting on these thoughts of killing yourself, as opposed to you have the thoughts, but you definitely would not act on them? (For example, “I had the thought of killing myself, but not sure if I would")")
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5. Have you started to work out, or actually worked out, the specific details of how to kill yourself and did you actually intend to carry out the details of your plan? (For example, “I am planning to take 3 bottles of my sleep medication)
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6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? (For example: Took pills, tried to shoot yourself, cut yourself, tried to hang yourself)
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New Patient?
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Mood Disorder Questionaire
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1. Has there ever been a period of time when you were not your usual self and…
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…you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
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…you were so irritable that you shouted at people or started fights or arguments?
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…you felt much more self-confident than usual?
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…you got much less sleep than usual and found you didn’t really miss it?
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…you were much more talkative or spoke faster than usual?
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…thoughts raced through your head or you couldn’t slow your mind down?
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…you were so easily distracted by things around you that you had trouble concentrating or staying on track?
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…you had much more energy than usual?
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…you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
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…you were much more active or did many more things than usual?
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…you were much more interested in sex than usual?
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…you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
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…spending money got you or your family in trouble?
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Please add up total number of YES responses for Question #1:
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2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?
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3. How much of a problem did any of these cause you —like being able to work; having family, money, or legal troubles; getting into arguments or fights?
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4. Have any of your blood relatives (ie, children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
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5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?
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Y-BOCS
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Obsessions
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1. How much of your time is occupied by obsessive thoughts?
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2. How much do your obsessive thoughts interfere with your work, school, social, or other important role functioning? Is there anything that you don’t do because of them?
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3. How much distress do your obsessive thoughts cause you?
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4. How much of an effort do you make to resist the obsessive thoughts? How often do you try to disregard or turn your attention away from these thoughts as they enter your mind?
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5. How much control do you have over your obsessive thoughts? How successful are you in stopping or diverting your obsessive thinking? Can you dismiss them?
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Compulsive Behaviors
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6. How much time do you spend performing compulsive behaviors? How much longer than most people does it take to complete routine activities because of your rituals? How frequently do you do rituals?
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7. How much do your compulsive behaviors interfere with your work, school, social, or other important role functioning? Is there anything that you don’t do because of the compulsions?
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8. How would you feel if prevented from performing your compulsion(s)? How anxious would you become?
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9. How much of an effort do you make to resist the compulsions?
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10. How strong is the drive to perform the compulsive behavior? How much control do you have over the compulsions?
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PCL-5
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In the past month, how much were you bothered by:
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1. Repeated, disturbing, and unwanted memories of the stressful experience?
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2. Repeated, disturbing dreams of the stressful experience?
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3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
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4. Feeling very upset when something reminded you of the stressful experience?
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5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
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6. Avoiding memories, thoughts, or feelings related to the stressful experience?
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7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
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8. Trouble remembering important parts of the stressful experience?
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9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
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10. Blaming yourself or someone else for the stressful experience or what happened after it?
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11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
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12. Loss of interest in activities that you used to enjoy?
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13. Feeling distant or cut off from other people?
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14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
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15. Irritable behavior, angry outbursts, or acting aggressively?
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16. Taking too many risks or doing things that could cause you harm?
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17. Being “superalert” or watchful or on guard?
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18. Feeling jumpy or easily startled?
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19. Having difficulty concentrating?
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20. Trouble falling or staying asleep?
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