Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Enter Email Confirm Email Patient Health Questionnaire PHQ-9Over the last 2 weeks, how often have you been bothered by any of the following problems? Read each item carefully and mark your response.Little interest or pleasure in doing things Not at all Several days More than half the days Nearly every day Feeling down, depressed, or hopeless Not at all Several days More than half the days Nearly every day Trouble falling asleep, staying asleep, or sleeping too much Not at all Several days More than half the days Nearly every day Feeling tired or having little energy Not at all Several days More than half the days Nearly every day Poor appetite or over eating Not at all Several days More than half the days Nearly every day Feeling bad about yourself - or that you are a failure or have let yourself or your family down Not at all Several days More than half the days Nearly every day Trouble concentrating on things such as reading the newspaper or watching television Not at all Several days More than half the days Nearly every day Moving or speaking so slowly that other people could notice. Or the opposite - being so fidgety or restless that you are moving around a lot more than usual Not at all Several days More than half the days Nearly every day Thoughts that you would be better off dead, or of hurting yourself in some way Not at all Several days More than half the days Nearly every day How difficult have these problems made it for you at work, home, or getting along with others? Not difficult at all Somewhat difficult Very difficult Extremely difficult AUDIT-C QuestionnaireHow often do you have a drink containing alcohol? Never Monthly or less 2 - 4 times a month 2 - 3 times a week 4 or more times a week When you do drink, how many standard drinks containing alcohol do you have on a typical day? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more N/A When you do drink, how often do you have six or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily Columbia-Suicide Severity Rating ScaleIn the past month, have you wished you were dead or wished you could go to sleep and not wake up? Yes No In the past month, have you actually had any thoughts about killing yourself? Yes No Have you thought about how you might do this? Yes No Have you had any intention on acting on these thoughts of killing yourself, as opposed to you have the thoughts but you definitely would not act on them? Yes No Have you started to work out or worked out the details of how to kill yourself? Yes No Did you intend to carry out this plan? Yes No In the past 3 months, have you done any of the following? Attempted to kill yourself even if ending your life was only part of your motivation Started to do something to end your life but someone or something stopped you before you actually did anything Started to do something to end your life but you stopped yourself before you actually did anything Taken any steps towards making a suicide attempt or preparing to kill yourself Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn't swallow any, held a gun but changed your mind or it was grabbed from your hand, wend to the roof but didn't jump; or actually took pills, tried to shoot yourself, tried to hang yourself, etc.In your entire lifetime, how many times have you done any of these things?GAIN-Short Screener (GAIN-SS)The following questions are about common psychological, behavioral, and personal problems. These problems are considered significant when you have them for two or more weeks, when they keep coming back, when they keep you from meeting your responsibilities, or when they make you feel like you can't go on.When was the last time that you had significant problems with feeling very trapped, lonely, sad, blue, depressed, or hopeless? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you had significant problems with sleep trouble, such as bad dreams, sleeping restlessly, or falling asleep during the day? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you had significant problems with feeling very anxious, nervous, tense, scared, panicked, or like something bad was going to happen? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you had significant problems with becoming very distressed and upset when something reminded you of the past? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you had significant problems with thinking about ending your life or committing suicide? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you did the following thing two or more times?Lied or conned to get things you wanted to avoid having to do something Past month 2 to 12 months ago 1+ years ago Never When was the last time that you did the following thing two or more times?Had a hard time paying attention at school, work, or home Past month 2 to 12 months ago 1+ years ago Never When was the last time that you did the following thing two or more times?Had a hard time listening to instructions at school, work, or home Past month 2 to 12 months ago 1+ years ago Never When was the last time that you did the following thing two or more times?Were a bully or threatened other people Past month 2 to 12 months ago 1+ years ago Never When was the last time that you did the following thing two or more times?Started physical fights with other people Past month 2 to 12 months ago 1+ years ago Never When was the last time that you used alcohol or other drugs weekly or more often? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or feeling the effects of alcohol or other drugs? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you kept using alcohol or other drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people? Past month 2 to 12 months ago 1+ years ago Never When was the last time that your use of alcohol or other drugs caused you to give up, reduce or have problems at important activities at work, school, home, or social events? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still or sleeping, or that you used any alcohol or other drugs to stop being sick or avoid withdrawal problems? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you had a disagreement in which you pushed, grabbed, or shoved someone? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you took something from a store without paying for it? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you sold, distributed, or helped to make illegal drugs? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you drove a vehicle while under the influence of alcohol or illegal drugs? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you purposely damaged or destroyed property that did not belong to you? Past month 2 to 12 months ago 1+ years ago Never Do you have other significant psychological, behavioral, or personal problems that you want treatment for or help with? Yes No If yes, please describe belowWhat is your gender? Select All Male Female How old are you today?Current SymptomsPlease check symptoms you currently experiencing Aches/pains Anxious/nervous Ashamed Blames others Body image concerns Can't enjoy myself Choking feeling Cry easily/often Depressed/sad Destroys property/fires Difficulty breathing Distressing memories Disturbing thoughts Dizziness Eating/appetite concerns Elevated mood Excessive worry Feel inferior Feel unworthy Feeling paranoid/suspicious Forgetful Frequent mood swings Frustration Guilt feelings Headaches Hear voices Heart racing Heavy feeling Hoarding Hopelessness Hyperactivity Impulsive Irritable/angry Lack of motivation Lies/steals Lonliness Lose temper Low energy/tired Low self-esteem Motor or verbal tics Nightmares Numbness/tingling Physical aggression/cruelty to animals Poor concentration Poor memory Racing thoughts Repetitive actions Restless/fidgety See images or objects Self-harming behaviors/urges Sexual issues/concerns Shaking Sleep problems Social discomfort Tense feelings Thoughts of wanting to die Thoughts of wanting to hurt others Wound up None reported Please list any other symptomsFinding Your ACE Score1. Did a parent or other adult in the household often … Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?YesNo2. Did a parent or other adult in the household often … Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?YesNo3. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Try to or actually have oral, anal, or vaginal sex with you?YesNo4. Did you often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?YesNo5. Did you often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?YesNo6. Were your parents ever separated or divorced?YesNo7. Was your mother or stepmother often pushed, grabbed, slapped, or had something thrown at her? Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?YesNo8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?YesNo9. Was a household member depressed or mentally ill or did a household member attempt suicide?YesNo10. Did a household member go to prison?YesNoAdd up your YES answers. Yes = 1Enter the total # of Yes answers.
