Supplementary Materials:
|
|
|
- Linette Curtis
- 6 years ago
- Views:
Transcription
1 Supplementary Materials: Depression and risk of unintentional injury in rural communities a longitudinal analysis of the Australian Rural Mental Health Study (Inder at al.) Figure S1. Directed acyclic graph (DAG) showing the presumed causal relationship between the exposure, outcome, and potential confounders/mediators. 1
2 Figure S2. Patterns of participation across the four waves of the ARMHS project. Survey 1: Baseline N = 2639 Survey 2: 12 month follow-up N = 1702 (64.5%) Survey 3: 3 year follow-up N = 1266 (48.0%) Survey 4: 5 year follow-up N = 1160 (44.0%) 2
3 Table S1. Characteristics of ARMHS participants: at baseline and by retention status. Characteristic Overall baseline At least one follow-up wave completed: sample (N = 2621): 1 No (N = 801) Yes (N = 1820) Age (years) - Mean (SD) 55.6 (14.7) 52.4 (16.0) 56.3 (13.9)** Gender Male 1065 (40.6) 334 (41.7) 731 (40.2) Female 1556 (59.4) 467 (58.3) 1089 (59.8) Educational level School Certificate (SC)/lower 742 (30.2) 261 (35.4) 481 (28.0)** Higher SC/trade/higher 1713 (69.8) 476 (64.6) 1237 (72.0) Marital status Married/de-facto 1963 (75.2) 584 (73.4) 1379 (76.1) Not partnered 646 (24.8) 212 (26.6) 434 (23.9) Employment status Employed/studying/home-duties 1610 (61.9) 502 (63.5) 1108 (61.1)* Unemployed/unable-to-work 203 (7.8) 76 (9.6) 127 (7.0) Retired 789 (30.3) 212 (26.8) 577 (31.8) History of chronic disease No 1471 (56.1) 474 (59.2) 997 (54.8) Yes 1150 (43.9) 327 (40.8) 823 (45.2) Serious accident No 2515 (97.5) 763 (97.2) 1752 (97.7) Yes 64 (2.5) 22 (2.8) 42 (2.3) Do you live on a farm No 1942 (75.1) 584 (74.0) 1358 (75.6) Yes 643 (24.9) 205 (26.0) 438 (24.4) ARIA ASGC category Inner regional 1010 (38.5) 296 (37.0) 714 (39.2) Outer regional 928 (35.4) 269 (33.6) 659 (36.2) Remote/very remote 683 (26.1) 236 (29.5) 447 (24.6) Alcohol consumption (AUDIT) Low-risk 1964 (85.8) 422 (86.5) 1542 (85.7) High-risk 324 (14.2) 66 (13.5) 258 (14.3) Likelihood of recent depression episode Unlikely 1431 (54.6) 436 (54.4) 995 (54.7) Somewhat likely 579 (22.1) 173 (21.6) 406 (22.3) Probable 611 (23.3) 192 (24.0) 419 (23.0) 1 Eighteen participants were excluded from this analysis as they only completed one of the three recent depression episode indicators. Column percentages are reported together with overall tests of association with retention status: * p < 0.01, ** p <
4 Table S2. Diagnostic accuracy analyses: used to identify/confirm cut-points for the three depression indicators and the composite index of the likelihood of a recent depression episode. ROC analyses of data from interviewed participants (stratified subset, N = 636), back-weighted to reflect baseline sample. Outcome: WHM-CIDI lifetime affective disorder diagnosis (Yes, N = 143; No, N = 493) Baseline measure AUC (99%CI) Selected threshold (depression indicator) % Above threshold Sensitivity Specificity LR+ LR- i) Psychological distress symptoms (K10) ii) Depression severity score (PHQ-9) iii) Self-reported depression (Ever told by a doctor) (0.644, 0.768) > % 63.0% 73.5% (0.652, 0.786) % 57.0% 85.3% (0.736, 0.860) Yes 28.8% 80.3% 79.4% Likelihood of recent depression episode (Sum of 3 indicators above): Probable ( 2 indicators) (0.788, 0.886) % 65.7% 81.4% Probable or Somewhat likely % 94.7% 63.9% Note: ROC, Receiver Operating Characteristic analysis; AUC, Area Under the Curve; LR+, Likelihood Ratio positive; LR-, Likelihood Ratio negative. Within the backweighted data, the rates of lifetime affective disorder across the composite index categories were: unlikely, 1.4%; somewhat likely, 20.8%; and probable, 36.3%; with an overall rate of 13.8%. Following Rogan and Gladen s approach [47], the true prevalence of lifetime affective disorder was estimated by applying the tabled sensitivity and specificity values to the baseline distributions of recent depression likelihood from Table 1 (N = 2621): using the probable cut-point (611/2621), true prevalence = 10.0% (99%CI: 5.5%, 14.5%); and using the probable or somewhat likely cut-point (1190/2621), true prevalence = 15.9% (99%CI: 11.6%, 20.1%). 4
5 Table S3. Cross-tabulated frequency distributions for the three depression indicators and the composite index of the likelihood of a recent depression episode by ARMHS survey wave. Likelihood of recent depression episode (during study wave) Depression indicator (0/1) based on: Survey 1 (Baseline, N = 2621) Survey 2 (12 months, N = 1675) Follow-up surveys: Survey 3 (3 years, N = 1249) Survey 4 (5 years, N = 1151) Overall (All waves, N = 6696) K10 PHQ-9 Ever told by doctor Unlikely (0) (54.6) 967 (57.7) 722 (57.8) 641 (55.7) 3761 (56.2) Somewhat likely (1) (9.6) 92 (5.5) 53 (4.2) 15 (1.3) 411 (6.1) (3.4) 48 (2.9) 43 (3.4) 55 (4.8) 236 (3.5) (9.1) 206 (12.3) 190 (15.2) 197 (17.1) 831 (12.4) Sub-total 579 (22.1) 346 (20.7) 286 (22.9) 267 (23.2) 1478 (22.1) Probable ( 2) (6.3) 112 (6.7) 57 (4.6) 52 (4.5) 385 (5.8) (6.7) 68 (4.1) 30 (2.4) 33 (2.9) 306 (4.6) (1.7) 34 (2.0) 22 (1.8) 49 (4.3) 150 (2.2) (8.7) 148 (8.8) 132 (10.6) 109 (9.5) 616 (9.2) Sub-total 611 (23.3) 362 (21.6) 241 (19.3) 243 (21.1) 1457 (21.8) Note: Likelihood of recent depression episode (during study wave) was based on three (0/1) depression indicators: K10 > 15 (for wave); PHQ-9 5 (for wave); and ever being told by a doctor that you have depression, stress or anxiety (cumulative across waves). Survey data were excluded from this analysis if only one of these three recent depression indicators was available. Across the study waves, 1457 surveys were categorized as indicating a recent probable depression episode, amongst which 42.3% (616) were positive on all three indicators, 31.3% (456) were positive on the ever told by doctor indicator plus one other, and a further 26.4% (385) were positive on both symptom measures (K10, PHQ-9). 5
6 Table S4. ARMHS symptom measures revisited (K10 and PHQ-9 item characteristics and profiles). Measure Item Table S4A. K10 and PHQ-9 item characteristics (internal consistency, crosscorrelations, component loadings): N = 2626 individuals, 4 ARMHS waves (6659 sets of K10 ratings; 6318 sets of PHQ-9 ratings) Kessler Psychological Distress Scale (K10) last 4 weeks: Corrected item - scale correlation (K10 or PHQ-9 total minus item) Cross-correlation with other scale (K10 or PHQ-9 total) Loading on First Principal Component (All 19 items) Q7: Depressed Q4: Hopeless Q10: Worthless Q8: That everything was an effort Q9: So sad that nothing could cheer you up Q5: Restless or fidgety Q2: Nervous Q6: So restless you could not sit still Q1: Tired out for no good reason Q3: So nervous that nothing could calm you down Patient-Health Questionnaire-9 (PHQ-9) - last 2 weeks: Q2: Feeling down, depressed or hopeless Q1: Little interest or pleasure in doing things Q6: Feeling bad about yourself, or that you are a failure, or have let yourself or your family down Q7: Trouble concentrating on things, such as reading the newspaper or watching television Q4: Feeling tired or little energy Q5: Poor appetite or overeating Q9: Thoughts that you would be better off dead, or of hurting yourself in some way Q3: Trouble falling or staying asleep, or sleeping too much Q8: Moving or speaking so slowly that other people could have noticed. Or the opposite: being so fidgety or restless that you have been moving around a lot more than usual Note: K10 items were rated on 1 ( None of the time ) to 5 ( All of the time ) scales, while PHQ-9 items were rated on 0 ( Not at all ) to 3 ( Nearly every day ) scales. Internal consistency (Cronbach alpha) coefficients: K10, 0.898; PHQ-9, 0.878; all 19 items, Items in this table are ranked (within scales) by their loading on the first principal component (from an analysis including all 19 items). The first principal component accounted for 48.26% of the item variance (eigenvalue = 9.169), with all items having moderate to high loadings. Correlation between K10 and PHQ-9 total scores, (N = 6262 sets of ratings). Using the cut-points for the binary depression indicators [K10 > 15 (for wave); PHQ-9 5 (for wave)], 24.9% of K10 scores were positive and 22.0% of PHQ-9 scores, with 85.0% concordance (overall Kappa coefficient, 0.584): 1001 (16.0%) above threshold on both; 560 (8.9%) only on the K10; 378 (6.0%) only on the PHQ-9; and 4323 (69.0%) below threshold on both. 6
7 Measure Item (Mean ratings) Table S4B. K10 and PHQ-9 item profiles (mean ratings) across depression likelihood index scores/categories: N = 2626 individuals, 4 ARMHS waves (6659 sets of K10 ratings; 6318 sets of PHQ-9 ratings). Likelihood of recent depression episode (during study wave) (Unlikely) (Somewhat likely) (Probable) Wald chi-squares for polynomial contrasts from GEE analyses (Trend components of change across depression likelihood) Linear Quadratic Cubic Kessler Psychological Distress Scale (K10) last 4 weeks: K10 total score ,385.31** 18.65** 16.86** Q7: Depressed ,414.69** 22.15** 8.32* Q8: That everything was an effort ,290.17** 8.86* 24.02** Q1: Tired out for no good reason ,134.69** ** Q2: Nervous ** Q5: Restless or fidgety * * Q4: Hopeless ** 20.87** 9.74* Q9: So sad that nothing could cheer you up ** 33.95** 4.04 Q10: Worthless ** 29.29** 1.79 Q6: So restless you could not sit still ** 7.18* 2.61 Q3: So nervous that nothing could calm you down ** 14.84** 0.95 Patient-Health Questionnaire-9 (PHQ-9) - last 2 weeks: PHQ-9 total score ,456.15** 53.38** 10.75* Q2: Feeling down, depressed or hopeless ,251.31** 54.58** 4.86 Q4: Feeling tired or little energy ,173.61** ** Q1: Little interest or pleasure in doing ,070.99** 40.24** 12.55** things Q3: Trouble falling or staying asleep, or ** * sleeping too much Q5: Poor appetite or overeating ** 12.61** 5.66 Q6: Feeling bad about yourself, or that you ** 43.53** 1.76 are a failure, or have let yourself or your family down Q7: Trouble concentrating on things, such ** 47.40** 1.38 as reading the newspaper or watching television Q8: Moving or speaking so slowly that ** 47.66** 2.61 other people could have noticed. Or the opposite: being so fidgety or restless that you have been moving around a lot more than usual Q9: Thoughts that you would be better off dead, or of hurting yourself in some way ** 36.06** 0.86 Note: Likelihood of recent depression episode (during study wave) was based on three (0/1) depression indicators: K10 > 15 (for wave); PHQ-9 5 (for wave); and ever being told by a doctor that you have depression, stress or anxiety (cumulative across waves). A separate generalized estimating equation (GEE) analysis was conducted for each item, controlling for study wave and within individual variation. Items in this table are ranked (within scales) by the overall strength of association with the depression likelihood index. Strong linear components of trend were evident for all 19 items, modest quadratic components for 14 items, and small cubic components for 8 items (with the non-linear elements being largely influenced by less marked differences between the 0 and 1 scores on the depression likelihood index): * p < 0.01; ** p <
PATIENT HEALTH QUESTIONNAIRE PHQ-9 FOR DEPRESSION
PATIENT HEALTH QUESTIONNAIRE PHQ-9 FOR DEPRESSION USING PHQ-9 DIAGNOSIS AND SCORE FOR INITIAL TREATMENT SELECTION A depression diagnosis that warrants treatment or treatment change, needs at least one
Brief Pain Inventory (Short Form)
Brief Pain Inventory (Short Form) Study ID# Hospital# Do not write above this line Date: Time: Name: Last First Middle Initial 1) Throughout our lives, most of us have had pain from time to time (such
Measurement of Psychopathology in Populations. William W. Eaton, PhD Johns Hopkins University
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike License. Your use of this material constitutes acceptance of that license and the conditions of use of materials on this
Mental Health measures workgroup Update. 14 th Washington Group meeting Buenos Aires 8-10 October 2014
Mental Health measures workgroup Update 14 th Washington Group meeting Buenos Aires 8-10 October 2014 Overview Discussion document revised Key considerations Review of most commonly used instruments Proposal
Appendix B: Screening and Assessment Instruments
Appendix B: Screening and Assessment Instruments Appendix B-1: Quick Guide to the Patient Health Questionnaire (PHQ) Purpose. The Patient Health Questionnaire (PHQ) is designed to facilitate the recognition
CBT Intake Form. Patient Name: Preferred Name: Last. First. Best contact phone number: address: Address:
Patient Information CBT Intake Form Patient Name: Preferred Name: Last Date of Birth: _// Age: _ First MM DD YYYY Gender: Best contact phone number: Email address: _ Address: _ Primary Care Physician:
PHARMACY INFORMATION:
Patient Name: Date of Birth: Referred by: Reason for Visit: Current psychiatric medications and doses: PHARMACY INFORMATION: Name of Pharmacy: Phone Number: Fax Number: Address: PRIMARY CARE PHYSICIAN
POST-STROKE DEPRESSION
POST-STROKE DEPRESSION Stroke Annual Review March 7 th & 8 th, 2018 Justine Spencer, PhD, CPsych OVERVIEW What is Post-Stroke Depression (PSD)? Risk factors/predictors Impact of PSD Treatment and Management
Jessica Gifford, LICSW Mental Health Educator Jessica Gifford, LICSW Mental Health Educator
Alleviating Depression and Anxiety through Wellness Promotion Jessica Gifford, LICSW Mental Health Educator Jessica Gifford, LICSW Mental Health Educator Public Health Approach Mental Health is a public
These questionnaires are used by psychology services to help us understand how people feel. One questionnaire measures how sad people feel.
ADAPTED PHQ-9 & GAD-7 QUESTIONNAIRES How to fill in these questionnaires: These questionnaires are used by psychology services to help us understand how people feel. One questionnaire measures how sad
Medicare Wellness Visit
of Birth: Today s : Medicare Wellness Visit Dear Patient, Your Medicare benefits include an Annual Wellness Visit to assist in preventing illness or detect illness at an early stage. Your Annual Wellness
Westminster IAPT Primary Care Psychology Service. Opt-In Questionnaire
Westminster IAPT Primary Care Psychology Service Opt-In Questionnaire In order to get a better idea of your difficulties, we would be grateful if you could complete the attached registration form and questionnaire.
PATIENT NAME: DATE OF DISCHARGE: DISCHARGE SURVEY
PATIENT NAME: DATE OF DISCHARGE: DISCHARGE SURVEY Please indicate whether you feel Living Hope Eating Disorder Treatment Center provided either Satisfactory or Unsatisfactory service for each number listed
To: Our Medicare Patients. Subject: Your Welcome to Medicare Exam
To: Our Medicare Patients Subject: Your Welcome to Medicare Exam Medicare covers a one-time Welcome to Medicare visit. The Welcome to Medicare visit must occur during your first twelve months as a Medicare
ADULT QUESTIONNAIRE. Date of Birth: Briefly describe the history and development of this issue from onset to present.
ADULT QUESTIONNAIRE Name: Address: Preferred phone number to reach you: Is it okay to leave a message? Yes No (Please check one) Date of Birth: Reason(s) for seeking treatment at this time? Briefly describe
Major Depressive Disorder Wellness Workbook
Framing Major Depressive Disorder Major Depressive Disorder Wellness Workbook This Workbook belongs to you and you decide how to use it. You decide who to show it to and whether or not you want someone
If you have any difficulties in filling out the forms, please contact our team administrator on
Westminster IAPT Primary Care Psychology Service Lisson Grove Health Centre Gateforth Street London NW8 8EG Team Administrator Tel: 07971315596 Dear Sir/Madam Thank you for requesting this opt-in pack
Peer Support / Social Activities Overview and Application Form
Peer Support / Social Activities Overview and Application Form What is Peer Support? Peer support is when people use their own experiences to help each other. What happens during peer support sessions
INSOMNIA SEVERITY INDEX
Name: Date: INSOMNIA SEVERITY INDEX For each of the items below, please circle the number that most closely corresponds to how you feel. 1. Please rate the CURRENT (i.e. last 2 weeks) severity of your
WELCOME TO AGEWELL MEDICAL ASSOCIATES
WELCOME TO AGEWELL MEDICAL ASSOCIATES We offer the following checklist and suggestions to help make your first visit as easy and pleasant as possible. What to bring with you: [ ] All of your medications
Objectives. Background and Significance. Background and Significance. Depression Screening: QIP in an Infectious Disease Primary Care Practice
Depression Screening: QIP in an Infectious Disease Primary Care Practice Karen Holen Lyda MS NP Paul F. Cook PhD Steven C. Johnson MD Objectives Describe relevance of identifying depression in a clinic
Depression Assessment and Management. John Kern MD Clinical Professor University of Washington
Depression Assessment and Management John Kern MD Clinical Professor University of Washington Handouts Antidepressant Treatment Flowchart Managing antidepressant nonresponse handouts 2 Diagnosis PHQ-9
Welcome to NHS Highland Pain Management Service
Welcome to NHS Highland Pain Management Service Information from this questionnaire helps us to understand your pain problem better. It is important that you read each question carefully and answer as
RN Behavioral Health Care Manager in Primary Care Settings
RN Behavioral Health Care Manager in Primary Care Settings Integrated Care and the Expanding Role of Nurses Seattle Airport Marriott, SeaTac, WA Tuesday, January 9, 2018 The Healthier Washington Practice
Sleep Health Center. You have been scheduled for an Insomnia Treatment Program consultation to further discuss your
Sleep Health Center You have been scheduled for an Insomnia Treatment Program consultation to further discuss your sleep. In the week preceding your appointment, please take the time to complete the enclosed
Lambeth Psychological Therapies
Complaints procedure: If you are not happy about your experience with our service, you can speak to a member of staff directly; alternatively, you can contact the PALS Office. To make a formal complaint,
Annual Wellness Visit Form 2016
Annual Wellness Visit Form 6 Initial G48/Subsequent G49 (circle one) Subjective: Past Medical History (mark X to confirm and note duration for chronic conditions only) Conditions Yrs Conditions Yrs Others:
Date of Birth (mm/dd/year): 2. How much would you like to weigh (desired weight)?
MFA Weight Management Practice Initial Consultation Survey Name: Date of Birth (mm/dd/year): I. Weight History 1. What is the main reason you want to lose weight? _ 2. How much would you like to weigh
Clinical Practice Guideline: Management of Major Depression in Primary Care
Clinical Practice Guideline: Management of Major Depression in Primary Care Approved, CHP Quality Improvement Committee 3/27/01, 10/22/02, 10/28/03, 11/2/04, 11/1/05, 9/8/09, 5/10/11, 5/14/13, 5/12/15,
Problem Summary. * 1. Name
Problem Summary This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every question
Rasch-scaling of PHQ-9 and GAD-7 Consequences for repeated assessments. Jan R. Böhnke & Jaime Delgadillo
Rasch-scaling of PHQ-9 and GAD-7 Consequences for repeated assessments Jan R. Böhnke & Jaime Delgadillo NHS::IAPT Improving Access to Psychological Therapies "Improving Access to Psychological Therapies
Prevalence of depression among patients with suspected tuberculosis at the Health Center of Duque de Caxias, Rio de Janeiro, Brazil
Prevalence of depression among patients with suspected tuberculosis at the Health Center of Duque de Caxias, Rio de Janeiro, Brazil Karina Marcia de Castro Silva Afrânio Kritski, Anna Cristina Calçada
SAN DIEGO SEXUAL MEDICINE
SAN DIEGO SEXUAL MEDICINE INTERNATIONAL INDEX OF ERECTILE FUNCTION (IIEF) These questions ask about the effects that your erection problems have had on your sex life over the last four weeks. Please try
Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol
PRE-EVALUATION FORM Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol High Blood Pressure Obesity Heart Defect
LifeBridge Physician Network Care Path Depression, Substance Abuse June 26, 2015
LifeBridge Physician Network Care Path Depression, Substance Abuse June 26, 2015 LBPN Care Path Aim: To develop and implement standard protocols, based on the best evidence, that provide a consistent clinical
Help is at hand. Lambeth. Problems at work? Depressed? Stressed? Phobias? Anxious? Can t find work? Lambeth Psychological Therapies
South London and Maudsley NHS Foundation Trust Problems at work? Lambeth Stressed? Depressed? Anxious? Phobias? Can t find work? Lambeth Psychological Therapies 020 3228 6747 Help is at hand Page 1 Are
Medicare Annual Wellness Visit HEALTH RISK ASSESSMENT
Patient Name: Date of Birth: GENERAL HEALTH 1. How is your overall health? Excellent Good Fair Poor 2. How many different prescriptions are you taking? 0-3 4-6 7-10 10+ 3. Do you take all of your mediations
INSTRUCTION MANUAL Instructions for Patient Health Questionnaire (PHQ) and GAD-7 Measures
PHQ and GAD-7 Instructions P. 1/9 INSTRUCTION MANUAL Instructions for Patient Health Questionnaire (PHQ) and GAD-7 Measures TOPIC PAGES Background 1 Coding and Scoring 2, 4, 5 Versions 3 Use as Severity
Conscious Living Counseling & Education Center 3239 Oak Ridge Loop East, West Fargo ND (701)
Conscious Living Counseling & Education Center 3239 Oak Ridge Loop East, West Fargo ND 58078 (701) 478-7199 INTAKE FORM BIRTH DATE: / / Age: Email: YOUR NAME FIRST: MIDDLE INITIAL: LAST: YOUR ADDRESS COMPLETE
o Normal Balanced Diet for your Age o High in Carbohydrates o High in Fats o High in Protein o Other Diet
HEALTH ASSESSMENT SCREENING FORM GO402 Welcome to G0438 First Annual G0439 Subsequent Other Code PATIENTS NAME: DATE OF BIRTH: DATE OF SERVICE: PLEASE LIST CURRENT MEDICATION, ALSO OVER THE COUNTER MEDICATIONS
DANA COKER KINGDON, PA
PERSONAL HEALTH HISTORY AGNES KINRA, MD, PA Board Certified in Internal Medicine DANA COKER KINGDON, PA 4104 West 15 th St # 101 Plano, TX 75093 Phone 972-596-0006 Fax 972-596-0904 Name (Last, First, M.I.):
PRIMARY MENTAL HEALTH CARE MINIMUM DATA SET. Scoring the Kessler 10 Plus
PRIMARY MENTAL HEALTH CARE MINIMUM DATA SET Scoring the Kessler 10 Plus 1 SEPTEMBER 2018 Page 2 of 6 Version History Date Details 14 September 2016 Initial Version 9 February 2017 Updated Version including
Christina Pucel Counseling 416 W. Main St Monongahela, PA /
ADULT INTAKE Name: Gender: M F DOB: Address: City: State: Zip: Telephone: Home Mobile Highest Level Education: Occupation: Emergency Contact: Relationship: Phone: Referred by: Family Members: Name Gender
Schodack Internal Medicine and Pediatrics. Annual Physical-Female
Schodack Internal Medicine and Pediatrics Annual Physical-Female Please Fill out this form (or have your caregiver complete it) and discuss with your medical provider. Thank you! Please Mark the preferred
STEP 1: Forms Please complete all the attached forms and bring them with you on the day of your visit.
PATIENT HEALTH HISTORY FORM DIRECTIONS AND VISIT DAY INSTRUCTIONS Prior to your Appointment: STEP 1: Forms Please complete all the attached forms and bring them with you on the day of your visit. STEP
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire Name: MR#:_ Date: Date of Injury: Referred By: Age: Date of Birth: Handed: R L Ambidextrous Male Female **** Mark
Please complete this form before your Doctor visit. We will review this together and make any changes needed.
1 Medical History Please complete this form before your Doctor visit. We will review this together and make any changes needed. Name Date of Birth Date of visit What is your height? weight? Medical History,
If you arrive at the office without these forms, your visit may need to be rescheduled.
Dear, Your Appointment for the Welcome to Medicare Visit OR Annual Wellness Visit is scheduled on at There is NO CO-PAY for this visit, so it is free for you. The goal of this visit is to provide time
Dr. Marc E. Lewis Dr. Meenakshi Aggarwal Anne Dunne, DNP Melinda Sanfilippo, FNP
Thank you for attending your annual health maintenance exam. Depending on your health insurance plan, you may receive preventative benefits for a reduced copay or no copay. We would like to clarify the
Primary Care Tool for Assessment of Depression during Pregnancy and Postpartum
HRSA-UIC Assessment of Depression Perinatal during Pregnancy Project: and Postpartum Primary Care Tool for Assessment of Depression during Pregnancy and Postpartum te to health care provider: This tool
Small-area estimation of prevalence of serious emotional disturbance (SED) in schools. Alan Zaslavsky Harvard Medical School
Small-area estimation of prevalence of serious emotional disturbance (SED) in schools Alan Zaslavsky Harvard Medical School 1 Overview Detailed domain data from short scale Limited amount of data from
*2927* For Office Use Only. BARIATRIC SURGERY CANDIDATE INFORMATION PACKET H /08;12/13;10/15 (d:\forms\hosp\.ofm) Initial appointment: Smoker:
MR # NAME DOB *2927* BASSETT MEDICAL CENTER Cooperstown, NY 13326-1394 DATE BARIATRIC SURGERY CANDIDATE INFORMATION PACKET H-2927 3/08;12/13;10/15 (d:\forms\hosp\.ofm) PLEASE PRINT CLEARLY NAME: DATE OF
EPWORTH SLEEPINESS SCALE
EPWORTH SLEEPINESS SCALE Name: Sponsors last 4 of SSN#: DOB: Today s Date: Age (years): Gender (circle): MALE FEMALE How likely are you to doze off or fall asleep in the following situation, in contrast
Dr. Marc E. Lewis Dr. Meenakshi Aggarwal Anne Dunne, FNP Melinda Sanfilippo, FNP
Thank you for attending your annual health maintenance exam. Depending on your health insurance plan, you may receive preventative benefits for a reduced copay or no copay. We would like to clarify the
Why Do I need an Annual Wellness Visit?
Why Do I need an Annual Wellness Visit? To Our Medicare Patients: Medicare covers once a year wellness exam. There is no deductible, copay or coinsurance with your wellness visit. Medicare is very specific
This product was developed by the RWJ Diabetes Self Management Program at Community Health Center, Inc. in Middleton, CT. Support for this product
This product was developed by the RWJ Diabetes Self Management Program at Community Health Center, Inc. in Middleton, CT. Support for this product was provided by a grant from the Robert Wood Johnson Foundation
Depression Care. Patient Education Script
Everybody has the blues from time to time, or reacts to stressful life events with feelings of anxiety, sadness, or anger. Normally these feelings go away with time but when they persist, and are present
Recognizing and Applying Tools to Alleviate Stress. Josie M. Rudolphi, PhD National Farm Medicine Center Marshfield, WI
Recognizing and Applying Tools to Alleviate Stress Josie M. Rudolphi, PhD National Farm Medicine Center Marshfield, WI Overview Stress in agriculture Stress and health Signs of stress and mental health
Name: Date of Birth: Age: Grade: ID Number: Bob M Jones 4/21/ Gender: Sexual Orientation: Sex at Birth: Preferred Pronoun:
JUST HEALTH PATIENT REPORT Name: Date of Birth: Age: Grade: ID Number: Bob M Jones 4/21/2000 17 12 1234567 Gender: Sexual Orientation: Sex at Birth: Preferred Pronoun: Femal Gay or Lesbian Female No pronouns,
SPIRIT CMTS Registry Example Patient for Care Manager Training
SPIRIT CMTS Registry Example Patient for Care Manager Training Getting Started The following scenario is designed to help you learn how to use the Care Management Tracking System (CMTS) registry to facilitate
Follow-up Questionnaire Page 1 of 10
(FQ1) Plate #330 Seq #005 Page 1 of 10 To s Date Demographics 1 What is your highest level of schooling or education? Primary or grammar school Some high school Graduated from high school Some college
HEADACHE MEDICINE NEW PATIENT QUESTIONNAIRE
1 HEADACHE MEDICINE NEW PATIENT QUESTIONNAIRE Name Date Age your headaches began (or how long ago did they start? ) Do you have more than one type of headache? Yes No If yes, answer the following questions
did you feel sad or depressed? did you feel sad or depressed for most of the day, nearly every day?
Name: Age: Date: PDSQ This form asks you about emotions, moods, thoughts, and behaviors. For each question, circle YES in the column next to that question, if it describes how you have been acting, feeling,
Anxiety is a feeling of fear, unease, and worry. The source of these symptoms is not always known.
Stress and Anxiety Stress can come from any event or thought that makes you feel frustrated, angry, or nervous. Anxiety is a feeling of fear, unease, and worry. The source of these symptoms is not always
USF Mood & Anxiety Disorders Program
QUICK INVENTORY OF DEPRESSIVE SYMPTOMATOLOGY (SELF-REPORT)(QIDS-SR16) Please circle the one response to each item that best describes you for the past seven days. 1. Falling Asleep: 0 I never take longer
Sec on 1 Demographic Informa on
The Priority Care Center A Program of the Humboldt IPA Primary Care Physician: Sec on 1 Demographic Informa on How were you referred: Name (Last, First, M.I.): A.K.A.: Date of Birth: Mailing Address: /
Chronic Condition Toolbook: Major Depressive Disorder. Focusing on Depression and Its Symptoms
Chronic Condition Toolbook: Major Depressive Disorder Focusing on Depression and Its Symptoms Table of Contents Focusing on Major Depressive Disorder... 1 Major Depressive Disorder Algorithm... 2 The Importance
Administering the PHQ-9 And Maximizing the Identification of Depression
Administering the PHQ-9 And Maximizing the Identification of Depression Presented by: Dr. Robert Figlerski, Director of Behavioral Health Services Team Health, New York Region Office: 914-949-1199 email:
Roy Zagieboylo, MD Assistant Professor University of Connecticut Family Medicine Department
Roy Zagieboylo, MD Assistant Professor University of Connecticut Family Medicine Department That weight gaining diet I put you on is really working! This won t hurt me a bit. You re in good shape for the
Section C: Depression
Section C: Depression TIME THIS SECTION BEGINS RECORDED HERE TSST11C C1. During the past 12 months, was there ever a time when you felt sad, blue, or depressed for two weeks or more in a row? B11C01 6.
HEALTH FOCUS: MENTAL HEALTH
HEALTH FOCUS: MENTAL HEALTH CONTENTS Introduction 1 Self-assessment quiz 2 Five steps to better mental 3 well-being Stress reduction exercises 4 Further support 5 INTRODUCTION There are two aspects to
MATCP When the Severity of Symptoms Interferes with Progress
MATCP 2017 When the Severity of Symptoms Interferes with Progress 1 Overview Stages of Change, or Readiness for Change Changing Behavior Medication Adherence Disruptive Behaviors Level of Care Tools including
CONCORD INTERNAL MEDICINE MENTAL HEALTH PROTOCOL
CONCORD INTERNAL MEDICINE MENTAL HEALTH PROTOCOL Douglas G. Kelling, Jr., MD Carla Gismondi-Eagan, MD, FACP George C. Monroe III, MD Revised April 8, 2012 The information contained in this protocol should
Name of Client: Former or Maiden name: Date of Birth: Age: SSN# Gender: Male Female
Adult Intake Forms LAKE COUNTRY ASSOCIATES, INC. 515 Bridge Street East, Park Rapids, MN 56470 ph: 218-366-9229 1426 Bemidji Ave NW, Ste 1 Bemidji, MN 56601 ph: 218-444-2233 Fax: 218-237-2520 11 Main Street
Naresh Patel, MD Texas Health Care Cardiology 508 S. Adams St. Suite 100 Fort Worth, TX Phone: (817) Fax: (817)
Naresh Patel, MD Texas Health Care Cardiology 508 S. Adams St. Suite 100 Fort Worth, TX 76104 Phone: (817) 877-8885 Fax: (817)332-9093 Patient's Name: DOB: Date: Email: What is the reason for your visit?
Medicare & Dual Options Annual Comprehensive Exam FAX COMPLETED FORM TO: Patient Personal Information
FAX COMPLETED FM TO: 877-682-2216 All fields marked with an * are required to be completed in order to receive payment for the ACE Form, unless indicated otherwise. Please refer to the document titled
Welcome to our practice! Please take a few moments to complete the following information.
Today s Date: Welcome to our practice! Please take a few moments to complete the following information. Personal Background Full Gender: Male Female Transgender Age: Race: White Black/African American
Can Animals Experience Emotions? Model Diagnostics Demographic variable Companion Animal. Deviance
1 2 3 Table 1: Table showing significant demographic influences on responses to the question can animals experience the following emotions? Significance of odds ratios: * p
This form must be completed electronically. Handwritten forms will not be accepted.
AUTHORITY: PURPOSE: PRE-DEPLOYMENT HEALTH ASSESSMENT PRIVACY ACT STATEMENT This statement serves to inform you of the purpose for collecting personally identifiable information through the DD Form 2795
SCL-90. Backaches 0 (T) In this case, the respondent experienced backaches a little bit (1). Please proceed with the questionnaire.
4-79 Name Date SCL-90 Below is a list of problems and complaints that people sometimes have. Please read each one carefully. After you have done so, select one of the numbered descriptors that best describes
The Revised Treatment Manual for the Brief Behavioral Activation Treatment for Depression (BATD-R) Pre - Session
The Revised Treatment Manual for the Brief Behavioral Activation Treatment for Depression (BATD-R) Pre-Session Key Elements: 1. Discussion of Depression Pre - Session 2. Introduction to Treatment Rationale
BEHAVIORAL HEALTH SCREENING TOOLS
BEHAVIORAL HEALTH SCREENING TOOLS FOR THE CO-LOCATION OF BEHAVIORAL HEALTH SERVICES IN A PRIMARY CARESETTING Date: August 29, 2017 Introduction Today s Presenter Jacqueline Delmont, MD, MBA Delmont Healthcare
South Australian Health & Wellbeing Survey
South Australian Health & Wellbeing Survey DECEMBER 2000 Eleonora Dal Grande Anne Taylor David Wilson Centre for Population Studies in Epidemiology South Australian Department of Human Services ACKNOWLEDGMENTS
GENERAL BEHAVIOR INVENTORY Self-Report Version Never or Sometimes Often Very Often
GENERAL BEHAVIOR INVENTORY Self-Report Version Here are some questions about behaviors that occur in the general population. Think about how often they occur for you. Using the scale below, select the
Spring 2013 Geriatric Health Lecture Series on Alzheimer s Disease and Related Issues. Depression. Stephen Thielke, MD
Spring 2013 Geriatric Health Lecture Series on Alzheimer s Disease and Related Issues Depression Stephen Thielke, MD Assistant Professor Department of Psychiatry and Behavioral Sciences University of Washington
Penn State Altoona Integrated care model Health services Counseling Services Disability Services Health Promotion
Penn State Altoona Integrated care model Health services Counseling Services Disability Services Health Promotion 4,000 undergraduates SAMHSA grant- 2009-2011 Topics Introduction Outcomes Statistics Screening
Impact of Nonresponse on Survey Estimates of Physical Fitness & Sleep Quality. LinChiat Chang, Ph.D. ESRA 2015 Conference Reykjavik, Iceland
Impact of Nonresponse on Survey Estimates of Physical Fitness & Sleep Quality LinChiat Chang, Ph.D. ESRA 2015 Conference Reykjavik, Iceland Data Source CDC/NCHS, National Health Interview Survey (NHIS)
Depression Fact Sheet
Depression Fact Sheet Please feel free to alter and use this fact sheet to spread awareness of depression, its causes and symptoms, and what can be done. What is Depression? Depression is an illness that
Supplementary Material
Bridges Between Bipolar and Borderline Personality Disorders: Clarifying Comorbidity Through the Analysis of Complex Network of Connections Between s Daniel Castro 1, Filipa Ferreira 1, Ana Sofia Mendes
GASTROINTESTINAL CANCER PREVENTION PROGRAM INTAKE FORM Page 1 of 6
Full Name Today s date Referred by: Primary Care Provider: What is the reason for your visit? Date of Birth FOR CLINIC USE ONLY HT (cm) WT (kg) Questions you would like addressed at this visit: Personal
DEPRESSION AND ANXIETY STATUS IN KANSAS
DEPRESSION AND ANXIETY STATUS IN KANSAS 2011 Behavioral Risk Factor Surveillance System This report was prepared by the Bureau of Health Promotion, Kansas Department of Health and Environment February
The start of Marc s story. at the beach. He walked to the beach at 3 o clock that morning and took off his
When Adults Feel Depressed: Late-Life Depressive Disorder Easy Read Volume # 18 Issue # 3 April 2008 Translated into plain language by Helen Osborne of Health Literacy Consulting Original article by Maria
Chapter 2 The validity of the Dutch K10 and EK10 screening scales for depressive and anxiety disorders
Chapter 2 The validity of the Dutch K10 and EK10 screening scales for depressive and anxiety disorders Published: Donker, T., Comijs, H.C., Cuijpers, P., Terluin, B., Nolen, W.A., Zitman, F.G., Penninx,
DEPRESSION IN THE ELDERLY POPULATION: A SONOMA COUNTY INTERVENTION
DEPRESSION IN THE ELDERLY POPULATION: A SONOMA COUNTY INTERVENTION Joyce A Goodwin EXECUTIVE SUMMARY Despite projections that disability rates will decline, the rapid growth of the older adult population
Diabetes distress 7 A s model
Diabetes and emotional health: A toolkit for health s supporting adults with type 1 or type 2 diabetes Diabetes distress 7 A s model AWARE Be AWARE that people with diabetes may experience diabetes distress
Integrating older age, disability and mental health issues into household surveys: progress and outstanding gaps
Integrating older age, disability and mental health issues into household surveys: progress and outstanding gaps Annex Emma Samman and Laura K. Rodriguez-Takeuchi 1. Selected survey questions: disability
Assessment of suicide risk (NZGG) Assessment of suicide risk
Appendix 1 Assessment of suicide risk (NZGG) Assessment of suicide risk Suicide assessment Have you had thoughts that life isn t worth living? Yes No Have you thought of harming yourself? Yes No Are you
Assessment Domains Screening Tools About this Domain (Screening Tools) In this Domain: HELPS Brain Injury Screen
Screening Tools About this Domain (Screening Tools) Health and human service experts have developed short questionnaires, or screening tools, to help professionals who are not experts in specific fields
Behavioral Risk Factor Surveillance Survey
Licking County Health Department Community Health Assessment Data Behavioral Risk Factor Surveillance Survey 28 A key strategic objective of the Licking County Health Department is to Monitor health status
QUALITY OF LIFE IN EPILEPSY - QOLIE-31 (Version 1.0)
QUALITY OF LIFE IN EPILEPSY - QOLIE-31 (Version 1.0) US English QOLIE-31 Copyright 1993, RAND. All rights reserved. The QOLIE-31 was developed in cooperation with Professional Postgraduate Services. Today