Indiana Polyclinic Combined Pain Scale Rate your pain according to the following scale Examples
|
|
|
- Leslie Davis
- 6 years ago
- Views:
Transcription
1 Indiana Polyclinic Combined Pain Scale Rate your pain according to the following scale Examples 0 No Pain No pain 0 1 Unpleasant Sensation - An occasional uncomfortable feeling. Almost no limit to function Mild skin irritation Minimal - Pain frequently brought to one s attention but acceptable. Able to engage in pleasures of life with some interference. Causes to avoid rigorous activities. Mild - Tolerable, but unsettling and on one s mind. Interferes with pleasures of life. Stops some productive activities. Mild to Moderate - Only short intervals of comfortable function; sometimes interrupts Activities of Daily Living, such as bathing and clothing and regularly prevents involvement in many tasks outside of the home. Decrease in job performance. Moderate - Pain constantly on one s mind; decrease in concentration, job performance and noticeably decreased enjoyment of life. Frequent missed work / time off. Cannot perform normal tasks without an increase in pain. Moderate to Severe - Significant limitations of Activities of Daily Living; productive activity/work is nearly impossible. Hard to do anything, but think of pain and ER visit. Severe - Difficulty doing more than basic chores; pain prevents productive activity. Frequent crying; pain is impossible to tolerate for long period of time without going to the ER. Debilitating - Causes uncontrollable moaning and distress and completely impairs productive activity. Cannot be still, can t maintain a reasonable conversation. It is impossible to put on a good face. Emergency medical attention is required. Agonizing - Individual cannot function; uncontrolled screaming and tearfulness. Emergency medical attention is required and hospitalization is recommended. Worst Imaginable - Paralyzing; person is in and out of consciousness and near death as a result of the pain. Emergency medical attention and hospitalization are required. Small bruise 2 Scraped knee, Jammed finger Major bruise, Ankle sprain 4 Moderate toothache, Headache for days 5 Day after major surgery pain 6 Stabbed with a knife, Broken leg 7 Natural childbirth, Small kidney stone Arm burning in a fire, Large kidney stone 9 Being torn apart while still alive 10
2 Indiana Polyclinic Combined Function Scale How is your overall daily function impacted by your pain? No Interference with Activity (Completely Independent) - Can complete daily activities; work/volunteer daily; active participant in family/social life; active on weekends, normal quality of life, complete household & yard work Slightly Modified Activity - Can take part in family and social life; can work/volunteer +hours daily; some weekend activity, complete household & yard work with increased fatigue but independent Minimal Limitations - Can work/volunteer a few hours daily; active 5+ hours/day; can plan & keep 1-2 social events during evenings/weekends; can complete household/yard work with some strain, may need help w/ select activities Mild Limitations - Can work in or out of home for few hours a week; active for -5 hours daily; can complete ADL s and household chores with help needed 15-25% of the time Mild to Moderate Limitations - Can complete some more complex household tasks with help needed 0-45% of the time; Occasional missed work/volunteer; limited social activities Moderate Limitations - Can leave the house only 1-2 times a week (unrelated to work or important appointments); can complete daily hygiene; can complete some daily household tasks with help needed half (50%) of the time Moderate to Severe Limitations - Can complete only simple household tasks with help needed 60% of the time, unable to grocery shop; can talk to others on phone; can only leave house for important appointments/emergencies Severe Limitations - In bed half the day almost every day; can get dressed, shower, watch TV, make phone calls & do minimal household tasks (needs help 70% of the time); leaves home only for emergencies, usually with assistance Severe to Maximal Limitations - In bed more than half the day every day, some contact with others in the home; limited self-care activity (needs help 0% of the time); leaves home only for emergencies and only with assistance Maximal Limitations - In bed most of the day every day; limited contact with others; minimal to no self-care activity (help needed 90% of the time), completely home bound 10 Totally Dependent - Unable to get out of bed all day every day; no self-care; no function possible without assistance
3 Indiana Polyclinic Combined Depression Scale 0 No Depression Full enjoyment of life Unpleasant Feelings - Feeling sad when sad things happen; able to get things done during the day as normal; 1 almost normal enjoyment of life Minimal - Sadness is noticeable but short in duration; able to get things done with little effort; normal life at 2 times may not be quite as enjoyable as it once was Mild - Sadness may occur but less than half the day; mild change in concentration/sleep; able to get things done with increased effort; frequently normal life may not be enjoyable as it once was Mild to Moderate Feels sad more than half the day; some noticeable changes in concentration, sleep and 4 appetite; may need some help completing normal activities of daily living such as chores at home; others may notice a decrease in your joy of life Moderate Feels sad most of the day; has decrease in concentration, happiness and activity that is noticed by 5 others; withdrawal from activities and friends; takes effort to complete activities such as chores at home; it takes an additional effort to enjoy most things Moderate to Severe Feels sad all day; significant changes in sleep, concentration and appetite; feelings of 6 hopelessness and guilt; little desire to complete activities; takes significant effort to complete any task; starting to feel like giving up; feels like most joy is gone and there is nothing pleasant to look forward to Severe - Constant sadness; frequent crying or feeling completely numb; inability to concentrate on simplest of 7 tasks; rare social connections; limited effort put forth for activities; actively avoids things that were once enjoyable; occasional thoughts of not wanting to live Debilitating - Severe sadness, worthlessness, guilt all day every day; uncontrolled crying and numbness; loss of most hope; sleeps much of day or rarely sleeps; almost no effort made to enjoy life; frequent thoughts of dying Agonizing - Unable to function; sleeps all day or can t sleep at all; no hope; limited communication with others; 9 complete numbness; life is completely joyless; constant thoughts of not wanting to live with a plan to end life. Hospitalization is required. Worst Imaginable - Only thought is to end life (with intent and plan); no functioning; no communication; what 10 once brought joy is now torture; others insist on taking individual to hospital or calling 911. Hospitalization is required.
4 Indiana Polyclinic Combined Anxiety Scale 0 No Anxiety 1 Unpleasant Feelings - Occasional worry/nervousness; normal for the situation 2 Minimal - Worry/nervousness is noticeable but short in duration; able to get things done with little effort Mild - Worry/nervousness less than half the day; mild change in concentration/sleep; uncomfortable physical sensations like stomach ache; able to get things done with extra effort Mild to Moderate - Worry/nervousness more than half the day; mild to moderate change in sleep and appetite; increase in fatigue, upset stomach, tension; more effort to concentrate and complete activities Moderate - Worry/nervousness most of the day; decrease in concentration noticed by others; feeling tension, fatigue, headaches; takes greater effort to complete activities; avoids some social situations Moderate to Severe - Worry/nervousness all day; significant change in sleep, appetite, concentration; very restless and/or nauseous; feeling panicky; avoids much activity due to discomfort and lack of focus Severe - Constant worry/nervousness; constant tension, nausea, difficulty breathing on occasion; unable to concentrate on simple tasks; limited contact with others; almost complete avoidance of activity; occasional thoughts of not wanting to live Debilitating - Severe worry/nervousness all day every day; severe stomach pain, headaches, tension; panic attacks almost daily; skin crawling; complete avoidance of activity and others; frequent thoughts of not living Agonizing - Unable to function; doesn t leave house; feeling completely paralyzed; unwanted/obsessive thoughts that will not stop; multiple panic attacks daily; constant thoughts of not living with a plan to end life. Hospitalization is required. Worst Imaginable - Only thought is to end life (with intent and plan); no functioning; no communication; others insist on taking individual to hospital or calling 911. Hospitalization is required.
5 Indiana Polyclinic STAR Evaluation* Patient Name: DOB: / / Date: MR#: In regards to the last 12 months 1. Have you felt depressed or anxious? YES NO 2. Have you noticed frequent mood swings? YES NO 2. Have you been unemployed? YES NO 1 4. Have you smoked cigarettes? YES NO 2 5. Have you felt that you smoke too much? YES NO 6. Have you drank more than three alcohol drinks per day most days? 7. Have you used recreational drugs?. Have you been treated for drug or alcohol problems? 9. Have you received pain medications from more than one doctor? 10. Have you been to more than one pain doctor or clinic? 11. Have you visited an emergency room for pain treatment? 12. Has anyone in your family (in or out of your home) had problems with drug or substance abuse? 1. Has there been any physical, sexual, or emotional abuse in your household? 14. Have you taken or borrowed prescription medication not prescribed to you? 15. Have you been arrested or had legal problems related to drugs or alcohol? YES NO 1 YES NO 2 YES NO YES NO 2 Key:, 10 = 1 2, 4, 11, 14 = 2 1, 5, 12, 1 = 6, 7,, 9, 15, 16 = 4 Total Score: *This evaluation has been modified from its original form. It is based on the STAR evaluation 200 EBSCO Publishing. Reprinted with permission for use in clinical practice Robert Friedman, MD, FACP, Victor Li, MD, and Deepak Mehrotra, MD. Department of Anesthesiology and Pain Medicine, Temple University Hospital, Philadelphia, Pennsylvania.
6 Indiana Polyclinic STAR Evaluation* Clinical Interpretation: High Risk (15+) Moderate Risk (7-14) Low Risk (0-6) Plan: Maintain Current Tx Plan Modify Tx Plan (list below) Refer to Outside Agency (i.e. inpatient treatment, IOP) Other: Supervisor Signature: Clinician Signature: Date: Date: *This evaluation has been modified from its original form. It is based on the STAR evaluation 200 EBSCO Publishing. Reprinted with permission for use in clinical practice Robert Friedman, MD, FACP, Victor Li, MD, and Deepak Mehrotra, MD. Department of Anesthesiology and Pain Medicine, Temple University Hospital, Philadelphia, Pennsylvania.
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
Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone:
Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone: Private email address: Student? If yes, where and major? May we leave
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,
Depression: More than just the blues
Depression: More than just the blues August 2011 Knowing When to Get Help Is it depression? How do you know if you re depressed? That s a good question! Depression can be a byproduct of stress and anxiety.
Class #2: ACTIVITIES AND MY MOOD
Class # Class #: ACTIVITIES AND MY MOOD CLASS OUTLINE I. Announcements & Agenda II. III. IV. General Review Personal Project Review Relaxation Exercise V. New Material VI. Personal Project I. Any Announcements?
ALLIANCE COMMUNITY HOSPITAL SLEEP DISORDERS CENTER PATIENT QUESTIONNAIRE/HISTORY PLEASE COMPLETE AND BRING WITH YOU ON THE NIGHT OF YOUR TEST.
ALLIANCE COMMUNITY HOSPITAL SLEEP DISORDERS CENTER PATIENT QUESTIONNAIRE/HISTORY PLEASE COMPLETE AND BRING WITH YOU ON THE NIGHT OF YOUR TEST. NAME DATE: HEIGHT: WEIGHT: DOB: SEX: HOME PHONE #: REFERRING
EMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION. Important Information
EMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION Important Information The primary purpose of an Emotional Support Animal (ESA) is to help his or her owner by decreasing symptoms that are associated
Ashok K. Modh, M.D., F.C.C.P. Naishadh K. Mandaliya, M.D., F.C.C.P. Jerges J. Cardona, M.D. Nirav B. Patel, M.D.
Ashok K. Modh, M.D., F.C.C.P. Naishadh K. Mandaliya, M.D., F.C.C.P. Jerges J. Cardona, M.D. Nirav B. Patel, M.D. Dear, Your physician has requested that you be scheduled for a sleep study. Your appointment
Re-Exam Questionnaire
Re-Exam Questionnaire Patient Name: Date: The following hi-lighted symptoms are what brought you into our office originally. DIRECTIONS: Please rate ALL hi-lighted symptoms: S = same; B = better; W = worse
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
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
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
EMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION PART I: PERSONAL INFORMATION STREET ADDRESS CITY/STATE
EMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION PART I: PERSONAL INFORMATION FIRST NAME LAST NAME EMAIL PHONE # STREET ADDRESS CITY/STATE ZIP GENDER: MALE FEMALE TRANSGENER MARITAL STATUS: MARRIED
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
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
UW MEDICINE PATIENT EDUCATION. Baby Blues and More DRAFT. Knowing About This in Advance Can Help
UW MEDICINE PATIENT EDUCATION Baby Blues and More Recognizing and coping with postpartum mood disorders Some women have baby blues or more serious postpartum mood disorders. It helps to know about these
Kelowna Sleep Clinic Dr. Ronald Cridland Inc Sleep Questionnaire
Dr. Ronald Cridland Inc Sleep Questionnaire Name: Date: d/m/yr Date of Birth: d/m/yr Age: Marital Status: Sex: M F Address: City: Province: Postal Code: Health Care #: Home Phone #: Work Phone #: _ Cell
RESEARCH DIAGNOSTIC CRITERIA FOR TEMPOROMANDIBULAR DISORDERS: REVIEW, CRITERIA, EXAMINATIONS AND SPECIFICATIONS, CRITIQUE
RESEARCH DIAGNOSTIC CRITERIA FOR TEMPOROMANDIBULAR DISORDERS: REVIEW, CRITERIA, EXAMINATIONS AND SPECIFICATIONS, CRITIQUE Edited by: Samuel F. Dworkin, DDS, PhD and Linda LeResche, ScD A. HISTORY QUESTIONNAIRE
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
ADULT INITIAL EVALUATION: Patient Form
ADULT INITIAL EVALUATION: Patient Form Date: Patient: DOB: Referred by: Name of Person completing this form if not patient: Briefly describe the events that led to this appointment. Have there been any
Medical History. Instructions. My telephone number is: 1 Tools Medical History
Medical History Instructions To do the best possible job with your pain, your doctor needs details about your history, including current and past medical problems, medications, health habits, and family
reasons for visit factors of complaint Date: Work comp injury Automobile accident Other injury
Date: LAST NAME FIRST NAME DATE OF BIRTH CURRENT AGE PRIMARY CARE PHYSICIAN PHONE NUMBER REFERRING PHYSICIAN PHONE NUMBER reasons for visit Work comp injury Automobile accident Other injury PRIMARY REASON
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
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
ADULT INTAKE FORM. Name
Welcome to Solace Counseling Associates. Please note that the information is important for your care. Please fill out forms as completely as possible and have them ready before your first counseling session.
Depression. Northumberland, Tyne and Wear NHS Trust (Revised Jan 2002) An Information Leaflet
Depression Northumberland, Tyne and Wear NHS Trust (Revised Jan 2002) An Information Leaflet practical ldren 1 7XR isle, d n. ocial These are the thoughts of two people who are depressed: I feel so alone,
PATIENT SURVEY FOR ADMINISTRATIVE USE ONLY. TO BE COMPLETED BY STUDY COORDINATOR.
PATIENT SURVEY FOR ADMINISTRATIVE USE ONLY. TO BE COMPLETED BY STUDY COORDINATOR. DATE OF VISIT: / / PATIENT ID: REGULAR PROVIDER: SITE OF VISIT: Cleveland Houston Manhattan Pittsburgh Thank you for agreeing
Module. Managing Feelings About. Heart Failure
Module 6 Managing Feelings About Heart Failure Taking Control of Heart Failure Contents Introduction 3 Common Feelings After a Diagnosis of Heart Failure 4 Recognizing Emotions After Diagnosis of Heart
International Childbirth Education Association. Postpartum Doula Program
International Childbirth Education Association Postpartum Doula Program Part 3: Postpartum Emotions Objective: Describe the range of possible postpartum emotions. List two factors that affect postpartum
COUPLE & FAMILY INSTITUTE OF TRI-CITIES AMEN ADULT GENERAL SYMPTOM CHECKLIST
COUPLE & FAMILY INSTITUTE OF TRI-CITIES AMEN ADULT GENERAL SYMPTOM CHECKLIST Please rate yourself on each symptom listed below. Please use the following scale: 0--------------------------1---------------------------2--------------------------3--------------------------4
Life, Family and Relationship Questionnaire
Date of Initial Session: Client Name Date of Birth Address City Zip Phone Number Email Emergency Contact Relationship Emergency Contact Ph. # Client Name: Date: Life, Family and Relationship Questionnaire
UW MEDICINE PATIENT EDUCATION. Baby Blues and More. Postpartum mood disorders DRAFT. Emotional Changes After Giving Birth
UW MEDICINE PATIENT EDUCATION Baby Blues and More Postpartum mood disorders Some new mothers have baby blues or more serious postpartum mood disorders. This chapter gives ideas for things you can do to
GENERAL INFORMATION PROFESSIONAL REFERRAL INFORMATION
SO THAT WE MAY BETTER SERVE YOU, PLEASE COMPLETE THE FOLLOWING FORM AND EITHER BRING THE COMPLETED FORM WITH YOU TO YOUR FIRST APPOINTEMNT OR SCAN IT AND EMAIL IT TO OFFICE, PRIOR TO YOUR APPOINTMENT LORRAINE@ANALIPSONMD.COM
Other significant mental health complaints
Other significant mental health complaints 2 Session outline Introduction to other significant mental health complaints Assessment of other significant mental health complaints Management of other significant
Coping with Advanced Stage Heart Failure and LVAD/Transplant. Kristin Kuntz, Ph.D. Department of Psychiatry and Behavioral Health
Coping with Advanced Stage Heart Failure and LVAD/Transplant Kristin Kuntz, Ph.D. Department of Psychiatry and Behavioral Health What is Health Psychology? Health psychology focuses on how biology, psychology,
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
LIST CHANGES IN YOUR MEDICATION OR SUPPLEMENTS INTAKE (add new meds, changes in old meds or meds you stopped taking) Are you taking it?
Date Patient name: LIST YOUR THREE MAIN COMPLAINTS FOR THIS VISIT - - - New med Old med LIST CHANGES IN YOUR MEDICATION OR SUPPLEMENTS INTAKE (add new meds, changes in old meds or meds you stopped taking)
BREAKING FREE FROM DEPRESSION AND DIABETES 10 THINGS YOU NEED TO KNOW AND DO
BREAKING FREE FROM DEPRESSION AND DIABETES 10 THINGS YOU NEED TO KNOW AND DO Depression is like a black hole. It can take the joy out of life, drain your energy and motivation, and cause you to feel hopeless
TAKING CARE OF YOUR FEELINGS
TAKING CARE OF YOUR FEELINGS A burn injury causes changes in your life. Even though the event or accident that caused the burn may be over, you may still experience strong emotional or physical reactions.
DBSA Survey Center Depression Experiences and Treatments Survey
Summary Report: May, 2017 BACKGROUND DBSA s was developed to identify experiences and challenges faced by individuals with depression, including what people are looking for in terms of treatment, their
Teen Stress and Anxiety Wayne Hills Counseling Dept. June, 2017
Teen Stress and Anxiety Wayne Hills Counseling Dept. June, 2017 True or False? 1. Even something positive, such as being selected for an award, can be stressful 2. The amount of stress you feel depends
Polysomnography Patient Questionnaire
Polysomnography Patient Questionnaire Date Medical Record # Demographics: Patient Name Date of Birth Address_ Home Phone Work Phone Cell Phone Height Weight Please complete each section of this questionnaire,
Emotions After Giving Birth
UW MEDICINE PATIENT EDUCATION Emotions After Giving Birth Baby blues and postpartum mood disorders Some women have baby blues or more serious mood disorders after having a baby. This handout gives ideas
Women, Mental Health, and HIV
Women, Mental Health, and HIV Together, we can change the course of the HIV epidemic one woman at a time. #onewomanatatime #thewellproject What is Mental Health? Refers to emotional, psychological, social
San Diego Center for the Treatment of Mood Disorders 1
San Diego Center for the Treatment of Mood Disorders 1 DATE NAME Last Middle First REFERRAL HISTORY: How did you find us (via a referral, web search, recommendation)? Please provide the name and phone
PEDIATRIC PAIN QUESTIONNAIRE Form A (Adolescent)
PEDIATRIC PAIN QUESTIONNAIRE Form A (Adolescent) Daniel P. Kohen, M.D. Developmental-Behavioral Pediatrics Partners-in-Healing of Minneapolis 10505 Wayzata Blvd - Suite 200 Minnetonka, MN 55305 763-546-5797
University Counselling Service
Bereavement The death of someone close can be devastating. There are no right or wrong reactions to death, the way you grieve will be unique to you. How you grieve will depend on many factors including
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:
A VIDEO SERIES. living WELL. with kidney failure LIVING WELL
A VIDEO SERIES living WELL with kidney failure LIVING WELL Contents 2 Introduction 3 What will I learn? 5 Who is on my healthcare team? 6 Who is affected by kidney failure? 6 How does kidney failure affect
Mental Health Assessment at End of Life Why Bother? P R E SENTED BY T R I SHA C U R IOZ, M SW, L I SW
Mental Health Assessment at End of Life Why Bother? P R E SENTED BY T R I SHA C U R IOZ, M SW, L I SW T R I SHA.CURIOZ@ALLINA.COM 6 1 2.262.7254 CONSULTATION WITH CONSULTING PHYSICIAN PHYSICAL SYMPTOMS
Your Child Deal With Depression
Helping Your Child Deal With Depression Susan Wood, M.A., C.Psych. October 19, 2013 Goals of presentation Symptoms/diagnosis of depression Risk factors and causes of depression Treatment and ways parents
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
USE THE LETTERS LISTED BELOW TO INDICATE
USE THE LETTERS LISTED BELOW TO INDICATE THE TYPE AND LOCATION OF YOUR PAIN & SENSATIONS A = ACHE B = BURNING S = STABBING N = NUMBNESS P = PINS & NEEDLES O = OTHER COMMENTS: COMMENTS: PT INITIALS DATE
UW MEDICINE PATIENT EDUCATION. Baby Blues and More. Knowing About This in Advance Can Help
UW MEDICINE PATIENT EDUCATION Baby Blues and More Recognizing and coping with postpartum mood disorders Some women have baby blues or more serious postpartum mood disorders. It helps to know about these
Depression: what you should know
Depression: what you should know If you think you, or someone you know, might be suffering from depression, read on. What is depression? Depression is an illness characterized by persistent sadness and
Patient Re-Examination Form
Harrisburg Family Chiropractic 220 S. Cliff Ave. Ste 106 Harrisburg SD 57032 (605) 767-7463 Name: Date: / / Patient Re-Examination Form Please fill out the information that has changed since your last
Sleep Questionnaire. 2. How long has this problem bothered you? My Main Sleep Complaints: - Trouble sleeping at night For how many months/ years?
Onslow Medical Specialties Clinic Lung Diseases & Sleep Disorders Clinic Pulmonary Function Test/ CardioPulmonary Exercise Test/ Thoracic Ultrasound Methacholine Challenge Test/ Video-Flexible Laryngoscopy/
Preferred Name (s): Local Address: City: State: Zip: Permanent Address: City: State: Zip: Years of Education: Occupation: Gender: M F
Today Date: Client Name(s) : Psychological Consultants Northgate Center 1210 ½ -7 th Street NW, Suite 216 Rochester, MN 55901 www.psychologicalconsultants1.com Office: (507) 252-9292 Fax: (507) 252-9203
Dr. Catherine Mancini and Laura Mishko
Dr. Catherine Mancini and Laura Mishko Interviewing Depression, with case study Screening When it needs treatment Anxiety, with case study Screening When it needs treatment Observation Asking questions
FMS Psychology, PLLC Adult Intake Form. Phone Number (Day): Phone Number (Evening):
FMS Psychology, PLLC Adult Intake Form General Information: Name: Date of Birth: / / Age: Gender: Address: Phone Number (Day): Phone Number (Evening): Primary Care Physician: Highest Level of Formal Education:
Do not write below this line DSM IV Code: Primary Secondary. Clinical Information
New Client Registration Today s date Name Age Sex Address Social security # Date of birth Home phone May I call you at this number? y / n Leave a message? y / n Other numbers at which I can call you Can
ALVIN C. BURSTEIN, MD PATIENT CLIENT INFORMATION
ALVIN C. BURSTEIN, MD PATIENT CLIENT INFORMATION LEGAL Name Date of Birth (must match insurance card) Address City State Zip Mailing Address City State Zip (If different) Phone: Cell Home Appt. reminders
Back and Neck Pain Questionnaire
www.orthonc.com Back and Neck Pain Questionnaire Please print legibly in black ink. Answer only questions applicable to your condition. Leave other spaces blank. Date you are filling out this form: PERSONAL
Depression During and After Pregnancy
Depression During and After Pregnancy Q: What is depression? A: Depression is more than just feeling blue or down in the dumps for a few days. It s a serious illness that involves the brain. With depression,
130 Preston Executive Drive Cary, NC Ph(919) Fax(919) Page 1 of 6. Patient History
130 Preston Executive Drive Cary, NC 27513 Ph(919)462-8081 Fax(919)462-8082 www.parkwaysleep.com Page 1 of 6 Patient History *Please fill out in dark BLACK INK only. General Information Name Sex: Male
APPLICATION FOR CARE AT CORE CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT CORE CHIROPRACTIC Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail
APPLICATION FOR CARE
3023 Eastland Blvd. Suite 101 Clearwater, FL 33761 Ph: 727-797-9900 Fax: 727-797-7695 APPLICATION FOR CARE Date: Name: Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Email Address: Birth
APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS HRN: Name: Birth Date: - - Age: o Male o Female Address: City: State:
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
NHS Fife Department of Psychology Depression. A Self Help Guide. Help moodcafe.co.uk
NHS Fife Department of Psychology Depression A Self Help Guide Help Yourself @ moodcafe.co.uk Depression is a very common problem and many people feel low or down in the dumps at times. This is often because
Mental Health in Youth: Symptoms, Treatment, Resources, and Hope. Town Hall Meeting Presentation Dr. June Restrepo January 24, 2019
Mental Health in Youth: Symptoms, Treatment, Resources, and Hope Town Hall Meeting Presentation Dr. June Restrepo January 24, 2019 Our ultimate focus is on Jesus Christ, not on the fallen world 2 Corinthians
Healing the Traumatized Family. Sean Smith MA, M.Ed., LPC, CAADC
Healing the Traumatized Family Sean Smith MA, M.Ed., LPC, CAADC Brené Brown Of all the things trauma takes away from us, the worst is our willingness, or even our ability, to be vulnerable. There's a reclaiming
WHAT IS STRESS? increased muscle tension increased heart rate increased breathing rate increase in alertness to the slightest touch or sound
EXAM STRESS WHAT IS STRESS? Stress is part of the body s natural response to a perceived threat. We all experience it from time to time. When we feel under threat, our bodies go into fight or flight response,
Deborah L. Galindo, Psy.D th St. SE, Ste 420 Salem, OR Phone: Fax: (503) or (503)
Deborah L. Galindo, Psy.D. 2601 25 th St. SE, Ste 420 Salem, OR 97302 Phone: 503-364-6093 Fax: (503) 566-9864 or (503) 364-5121 COUPLES THERAPY INTAKE QUESTIONNAIRE (EACH PARTNER NEEDS TO COMPLETE THIS
Sonja Benson, Ph.D., PLLC Licensed Psychologist
Sonja Benson, Ph.D., PLLC Licensed Psychologist Date_ Referred by Name Date of Birth Social Security # Address_ City State Zip code Daytime Phone Nighttime Phone Cell Phone Email Male( ) Female ( ) Ethnicity
General Questionnaire
General Questionnaire Name: Date: Address:_ Home Phone: Alternate number: Occupation: Age: Height: Weight: Weight 6 months ago: At age 20: At your heaviest: Referring Physician: Family Physician: 1. In
Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC
Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC aylacarter@fullcirclepsychotherapy.org www.fullcirclepsychotherapy.org (253) 686-4681 Name (First, Middle, last): Birthdate: Age: Gender: Sexual Orientation:
Patient Assessment Form
www.licencetogrow.ca info@licencetogrow.ca Patient Assessment Form PATIENT INFORMATION FIRST Name: LAST Name: Date of Birth: Address: Height: Weight: Gender: Home Phone: Email Address: SKYPE User Name:
Parent Pain Questionnaire Understanding your child s pain
Parent Pain Questionnaire Understanding your child s pain This questionnaire is to help us learn about your child's pain problems. All information obtained from this questionnaire and in interviews will
Caring for the Caregiver
Caring for the Caregiver Understanding and Managing the effects of caregiving Finding Your Caregiving Stress Index Define the Role of Stress and its Negative Effects Creating a Wellness Model Ten Step
PHONE: RELATIONSHIP: ADDRESS:
Les Fehmi, Ph.D. 317 Mt. Lucas Road Princeton NJ 08540 609.924.0782 Fax: 609.924.0782 lesfehmi@openfocus.com www.openfocus.com Date: Interviewer: Referred By: 1. NAME: MALE/FEMALE BIRTH DATE: / / 2. ADDRESS:
THE INSPIRED LIVING MINDFULNESS MEDITATION PROGRAMME
THE INSPIRED LIVING MINDFULNESS MEDITATION PROGRAMME 1 Foreword More and more research is proving that Mindfulness can help us to overcome addictions, stress, fear, anxiety and even depression. Mindfulness
Mood, Emotions and MS
Mood, Emotions and MS Catherine Condon Clinical Neuropsychologist Integrated Psychology Living Well with MS Living a full and meaning-filled life Social connection Valued activity Healthy exercise Healthy
Abusing drugs can reduce the effectiveness of your treatment, prolong your illness and increase the risk of side effects.
Depression: This brochure can help you learn more about depression. It does not replace regular medical check-ups or your health care provider s advice. Talk with your health care provider about what you
DEPRESSION. There are a couple of kinds, or forms. The most common are major depression and dysthymic disorder.
DEPRESSION OBJECTIVES: At the end of this class, you will be able to: 1.list and describe several kinds of depression, 2.discuss the signs of depression, and 3.relate the treatment of depression. INTRODUCTION
Child/ Adolescent Questionnaire
Oconee Center for Behavioral Health 1360 Caduceus Way Building 400, Suite 102 Tel 706-286-8442 Fax 706-310-6907 Child/ Adolescent Questionnaire Patient s Name: Date of Birth: / / Patient s Birthplace:
Understanding Complex Trauma
Understanding Complex Trauma Frightening events can have lasting effects Trauma and Homelessness Team Carswell House Dennistoun Glasgow G31 2HX Tel: 0141 232 0114 Fax: 0141 232 0131 General enquiries email:
To be completed by Patient. Client Questionnaire
Date: To be completed by Patient Client Questionnaire Client(s) Name: SSN#: - - Name of Person Completing Form: Relationship to Patient: (if other than client) Marital Status of Client Race/Ethnic Origin
The Rehabilitation Institute Cancer Rehabilitation
DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation STAR Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors
FACTSHEET F37. COpIng with LOw MOOD/ DEpRESSIOn
COpIng with LOw MOOD/ DEpRESSIOn If you are living with a chest, heart or stroke condition you may have periods when your mood is low: this is quite common. Feeling down for some of the time is a natural
Determining Major Depressive Disorder in Youth.
Co-parenting chapter eight. Watching for Depression in Yourself and Your Child. by Yvonne Sinclair M.A. If you notice your child has been feeling sad most of the day and can t seem to shake that down feeling,
Minor Intake Form. Child s Name DOB
Page 1 of 5 Minor Intake Form Child s NameDOB Current Concerns: What concern brings you or your child in? When did this concern begin? (Please attempt to use dates.) Has your family/child been in therapy
The Rehabilitation Institute Cancer Rehabilitation
DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors
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
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
In order to receive the maximum benefit from your rehabilitation program, it is important to understand and comply with the following guidelines:
Arrival Policy 900 2 nd Ave., Madison, MN 56256 In order to receive the maximum benefit from your rehabilitation program, it is important to understand and comply with the following guidelines: Attend
New Client Information. address: Date of Birth:
Milwaukee Area Psychological Services, S.C. (MAPS) 401 E. Kilbourn Avenue, Suite 402 Milwaukee, WI 52302 414-269-8660 (phone) 414-269-8656 (fax) New Client Information Your responses to the following questions
Nebraska Bariatric Medicine 8207 Northwoods Dr., Suite 101 Lincoln, NE MEDICAL HISTORY
Nebraska Bariatric Medicine 8207 rthwoods Dr., Suite 101 Lincoln, NE 68505 MEDICAL HISTORY Name Today s Date The following page allows you to complete what we call a weight timeline. This is a very valuable
MEDICAL HISTORY QUESTIONNAIRE
MEDICAL HISTORY QUESTIONNAIRE NAME: SEX: DATE: DOB: AGE: Primary Doctor / Care Manager: Additional doctors to receive sleep study results: Chief sleep related complaint: What made you decide to have this
Arizona Injury Medical Associates, P.L.L.C. Physiatry Care
GENERAL INFORMATION HISTORY QUESTIONNAIRE Name: Today s Date: Age: Date of birth: Sex: M F SS#: Home Address: Cell Phone: Your doctor: Home Phone: Your Attorney (if any): If questions arise after today