PATIENT NAME: FIRST MIDDLE LAST ADDRESS: ADDRESS: PERSON TO NOTIFY IN CASE OF EMERGENCY: RELATIONSHIP: PHONE NUMBER(S):

Transcription

1 PATIENT REGISTRATION PATIENT NAME: FIRST MIDDLE LAST INITIALS: (first, middle, last) GENDER: MALE FEMALE (circle one) BIRTHDATE: / / AGE: ADDRESS: HOME PHONE: ( ) - EMPLOYER: CELL/PAGER: ( ) - WORK PHONE: ( ) - ADDRESS: PERSON TO NOTIFY IN CASE OF EMERGENCY: RELATIONSHIP: PHONE NUMBER(S): HOW DID YOU HEAR ABOUT OUR PROGRAM?

2 DEMOGRAPHIC INVENTORY Today s Date / / M M D D Y Y Y Y 1. Race/Ethnicity Ethnicity Hispanic Non-Hispanic Race American Indian or Alaskan Native Asian Black or African American White Native Hawaiian or Other Pacific Islander Other 2. Current marital status (Check one): Single, never married Married, living together Separated Widowed Cohabiting with partner Married, not living together Divorced 3. If you are married or cohabitating with partner, how long has this been? Years Months 4. Number of previous marriages? 5. How many children do you have? 6. TOTAL number of persons including yourself in your household? 7. How many years of formal education have you completed? 8. Highest degree obtained: (Check only one) Years High school graduate M.B.A./M.A./M.S./M.P.H. G.E.D. J.D./LL.B. Junior college degree or M.D. technical school diploma Ph.D. 4 year college degree Other: 9. What best describes your current employment status? (Check one from each category a, b, & c) a. Employment Status b. Student Status c. Volunteer Status Unemployed, not looking for employment Part-time Volunteer Part-time Unemployed, looking for employment Full-time Volunteer Full-time Full-time employed Not a student No Volunteer Work Part-time employed Retired, not working Self-employed for pay

3 10. Type of occupation? (Check only one) Professional specialty Service, except private households & protective Technical and related support Precision production, craft and repair Sales Machine operators, assemblers and inspectors Administrative support, including clerical Transportation and material moving occupations Private Household Handlers, equipment cleaners, helpers and laborers Protective Service Farming, forestry and fishing Spousal Information 11. How many years of formal education has your spouse completed? 12. Highest degree your spouse has obtained: (Check only one) Years High school graduate M.B.A./M.A./M.S./M.P.H. G.E.D. J.D./LL.B. Junior college degree or M.D. technical school diploma Ph.D. 4 year college degree Other: 13. What best describes your spouse s current employment status? (Check one from each a, b, & c) a. Employment Status b. Student Status c. Volunteer Status Unemployed, not looking for employment Part-time Volunteer Part-time Unemployed, looking for employment Full-time Volunteer Full-time Full-time employed Not a student No Volunteer Work Part-time employed Retired, not working Self-employed for pay 14. Spouse s type of occupation? (Check only one) Professional specialty Service, except private households & protective Technical and related support Precision production, craft and repair Sales Machine operators, assemblers and inspectors Administrative support, including clerical Transportation and material moving occupations Private Household Handlers, equipment cleaners, helpers and laborers Protective Service Farming, forestry and fishing Household: income 0 - $24,999 $50,000-$74,999 $100,000+ Zip Code : $25,000-$49,999 $75,000-$99,999 Current residence : What is the major mode of Detached house Retirement complex transportation that you use? Rooming house or hotel or senior housing (check one) Rowhouse or townhouse Healthcare facility Bus/rail system Train Mobile home or nursing home Car Walk Apartment or condominium Homeless

4 MEDICAL & MENTAL HEALTH HISTORY Have you ever had any of the following (check all that apply): Chest pain/pressure/tightening High Blood Pressure Heart attack Stroke Headaches Head injury Paralysis Seizures or Convulsions Memory loss Dizzy Spells Difficulty hearing Asthma Shortness of breath TB / Lung disorder History of cancer or tumors Ulcers Colitis Digestive problems Diabetes Thyroid problems Glaucoma Cataracts Hepatitis (Liver Disease) Anemia Mononucleosis Arthritis Kidney infections Allergies Skin rash Other (list) Please list current or past medications you have taken for the treatment of any medical problem. Medical Problem Medication (name/dose) Start Date Stop Date Currently Taking? What kind of birth control are you using? How much alcohol, including beer, do you drink per week?

5 Mental Health History Have you ever had a problem with any of the following (check all that apply): Depression Anxiety Panic Attacks Post Traumatic Stress Bipolar (Manic / Depressive) Disorder Schizophrenia Alcohol Problems (including AA) Drug Problems Other (list) Please list current or past medications you have taken for treatment of any mental health problem. Problem (e.g. Depression, Anxiety) Medication (name and highest dose) Start Date Stop Date Why stopped (e.g. felt better, didn t help) Has anyone in your family ever been treated for any of the following (check all that apply): Mother Father Aunt Uncle Brother Sister Children Depression Anxiety Panic Attacks Post Traumatic Stress Bipolar (Manic / Depressive) Disorder Schizophrenia Alcohol Problems (including AA) Drug Problems Are you currently seeing a counselor or therapist? Are you having problems concentrating or problems remembering things?

6 Additional Medications Please list any medications you are taking that have not been listed above, including birth control pills, any over the counter medications and herbal remedies (i.e. decongestants, St. John's Wart, vitamins). Medication (name/dose) Start Date Stop Date Physician Medication Allergies Medication (name/dose) Type of Reaction Physical Activity YES NO Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? YES NO Do you feel pain in your chest when you do physical activity? YES NO In the past month, have you had chest pain when you were doing physical activity? YES NO Do you lose you balance because of dizziness or do you ever lose consciousness? YES NO Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? YES NO Is you doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? YES NO Do you know of any other reason why you should not do physical activity? How much do you exercise each week?

7 UTSW Antidepressant Treatment History Evaluation Have you taken any of the anti-depressant medications listed below? If yes, please indicated: 1) What dosage did you take? 2) How many weeks did you take the medication? 3) Did it result in 50% reduction of depressive symptoms? 4) Did you have any troubling side effects that made it difficult to take the medication? Anti-Depressant Medication Dose Taken Weeks Taken 50% Reduction in Symptoms Troubling Side Effects Citalopram or CELEXA mg Yes No Yes No Fluoxetine or PROZAC mg Yes No Yes No Paroxetine or PAXIL mg Yes No Yes No Escitalopram or LEXAPRO mg Yes No Yes No Sertraline or ZOLOFT mg Yes No Yes No Paroxetine CR or PAXIL CR mg Yes No Yes No Fluvoxamine or LUVOX mg Yes No Yes No Duloxetine or CYMBALTA mg Yes No Yes No Venlafaxine XR or EFFEXOR XR mg Yes No Yes No Mirtazapine or REMERON mg Yes No Yes No Bupropion or WELLBUTRIN mg Yes No Yes No Nortriptyline or PAMELOR mg Yes No Yes No Protriptyline or VIVACTIL mg Yes No Yes No Amitriptyline or ELAVIL mg Yes No Yes No Amoxapine or MOXADIL mg Yes No Yes No Imipramine or TOFRANIL mg Yes No Yes No Desipramine or NORPRAMINE mg Yes No Yes No Trimipramine or SURMONTIL mg Yes No Yes No Clomipramine or ANAFRAMIL mg Yes No Yes No Maprotilene or LUDIOMIL mg Yes No Yes No Doxepin or SINEQUAN mg Yes No Yes No Nomifensine or MERITAL mg Yes No Yes No Isocarboxazid or MARPLAN mg Yes No Yes No Tranylcypromine or PARNATE mg Yes No Yes No Phenelzine or NARDIL mg Yes No Yes No Trazodone or DESYREL mg Yes No Yes No Nefazodone or SERZONE mg Yes No Yes No Selegiline or EMSAM mg Yes No Yes No

8 DIAGNOSTIC SCREENING QUESTIONNAIRE (DSQ) Name: Age: Gender: M OR F Date: 1. YES NO There have been times when I felt down, depressed, or sad for several weeks in a row. 2. YES NO There have been times when I lost interest or pleasure in things I usually enjoyed, and it lasted for several weeks in a row. If you answered YES to questions 1 or 2, when you felt that way did you also notice. YES NO Not feeling like eating...or the opposite, eating more than usual. YES NO Not getting enough sleep...or the opposite, sleeping too much. YES NO Feeling restless and couldn't sit still...or the opposite, feeling slowed down. YES NO Feeling low in energy or getting tired for no reason. YES NO Feeling guilty most of the time or feeling worthless. YES NO Having trouble concentrating or trouble making decisions. YES NO Thinking that life is not worth living or thinking about dying. YES NO Have you been feeling this way the last 2 weeks? If YES, how long have you felt this way? YES NO Have you felt this way before? If YES, how many times have you felt this way? How old were you when you first felt this way?

9 3. YES NO I have had a period of six months or more when I worried excessively and found it difficult to control my anxiety. If you answered YES to question 3 please answer the following questions. More days than not during the last 6 months: YES NO I worried excessively and found it difficult to control my anxiety. YES NO I felt tense or keyed-up, or felt restless. YES NO I have had trouble concentrating or my mind goes blank at times. YES NO I have felt easily annoyed or irritable. YES NO I have had tense or sore muscles. YES NO I have not been getting enough sleep. 4. YES NO I have had a panic attack when I suddenly felt frightened or anxious or suddenly developed a lot of physical symptoms. The symptoms may have included some of the following: heart pounding or racing, sweating, shaking or trembling, shortness of breath, choking feeling, chest pain, upset stomach, feeling dizzy or faint, feeling spaced-out, fear of losing control, fear of dying, numbness or tingling, chills or hot flushes. If you answered YES to question 4 please answer the following questions. The month after this happened did you: YES NO I had a lot of concern about this happening again. (For example you may have been concerned that if it happened again you might lose control, or have a heart attack.) YES NO I changed what I was doing or where I was going because I was concerned that this might happen again. YES NO This only happens to me in certain situations. Some of the situations are things such as: seeing a snake or a dog; being in a storm; being in high places; going swimming; seeing blood; being in places that are small and enclosed; driving the car; having to talk or perform in front of people; going to crowded places; etc. 5. YES NO I have been bothered by thoughts that did not make any sense and kept coming back even when I tried not to have them. 6. YES NO I cannot resist doing some things over and over again, like washing my hands repeatedly, or checking the same thing repeatedly, or counting things. 7. YES NO I keep thinking about, or dreaming about a traumatic event that involved me or someone I cared about. The event(s) were life threatening, such as a serious accident, a physical assault, or seeing someone killed or badly injured.

10 8. YES NO There have been days when I was feeling so good, high, excited, irritable, or hyper that other people thought I was not my normal self or I got into trouble. 9. YES NO There have been days when I felt so good about myself that I thought I could do just about anything. 10. YES NO There have been times when I only needed a couple of hours of sleep each night. 11. YES NO There have been days when other people noticed that I was talking a lot more than usual. 12. YES NO There have been days when my thoughts seemed to be racing through my head. 13. YES NO There have been days when I was easily distracted and had trouble paying attention. 14. YES NO There have been times when I started so many projects that I could never finish them all. 15. YES NO There have been times when I did a lot or reckless things such as, spending a lot of money on things I didn t need, or getting sexually involved with people I normally would not get involved with. If you answered YES any of the questions 8 through 15, please answer the following questions. YES NO Did this last for more than 4 days in a row? YES NO Did this last for a week or more? YES NO I have felt some of these things in the last week? 16. YES NO I have heard things that other people couldn t hear, such as noises, or the voices of people whispering or talking. 17. YES NO I have seen visions or have seen things that other people couldn t see. 18. YES NO I have had a problem with alcohol or drug use...or my friends, family, or employers have told me they thought I had a problem with alcohol or drug use. Comments:

11 QUICK INVENTORY OF DEPRESSIVE SYMPTOMATOLOGY (SELF-REPORT) (QIDS-SR 16 ) Subject ID Date 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 than 30 minutes to fall asleep. 1 I take at least 30 minutes to fall asleep, less than half the time. 2 I take at least 30 minutes to fall asleep, more than half the time. 3 I take more than 60 minutes to fall asleep, more than half the time. 2. Sleep During the Night: 0 I do not wake up at night. 1 I have a restless, light sleep with a few brief awakenings each night. 2 I wake up at least once a night, but I go back to sleep easily. 3 I awaken more than once a night and stay awake for 20 minutes or more, more than half the time. 6. Decreased Appetite: 0 There is no change in my usual appetite. 1 I eat somewhat less often or lesser amounts of food than usual. 2 I eat much less than usual and only with personal effort. 3 I rarely eat within a 24-hour period, and only with extreme personal effort or when others persuade me to eat. 7. Increased Appetite: 0 There is no change from my usual appetite. 1 I feel a need to eat more frequently than usual. 2 I regularly eat more often and/or greater amounts of food than usual. 3 I feel driven to overeat both at mealtime and between meals. 3. Waking Up Too Early: 0 Most of the time, I awaken no more than 30 minutes before I need to get up. 1 More than half the time, I awaken more than 30 minutes before I need to get up. 2 I almost always awaken at least one hour or so before I need to, but I go back to sleep eventually. 3 I awaken at least one hour before I need to, and can't go back to sleep. 4. Sleeping Too Much: 0 I sleep no longer than 7-8 hours/night, without napping during the day. 1 I sleep no longer than 10 hours in a 24-hour period including naps. 2 I sleep no longer than 12 hours in a 24-hour period including naps. 3 I sleep longer than 12 hours in a 24-hour period including naps. 5. Feeling Sad: 0 I do not feel sad 1 I feel sad less than half the time. 2 I feel sad more than half the time. 3 I feel sad nearly all of the time. 8. Decreased Weight (Within the Last Two Weeks): 0 I have not had a change in my weight. 1 I feel as if I've had a slight weight loss. 2 I have lost 2 pounds or more. 3 I have lost 5 pounds or more. 9. Increased Weight (Within the Last Two Weeks): 0 I have not had a change in my weight. 1 I feel as if I've had a slight weight gain. 2 I have gained 2 pounds or more. 3 I have gained 5 pounds or more. 10. Concentration/Decision Making: 0 There is no change in my usual capacity to concentrate or make decisions. 1 I occasionally feel indecisive or find that my attention wanders. 2 Most of the time, I struggle to focus my attention or to make decisions. 3 I cannot concentrate well enough to read or cannot make even minor decisions.

12 11. View of Myself: 0 I see myself as equally worthwhile and deserving as other people. 1 I am more self-blaming than usual. 2 I largely believe that I cause problems for others. 3 I think almost constantly about major and minor defects in myself. 12. Thoughts of Death or Suicide: 0 I do not think of suicide or death. 1 I feel that life is empty or wonder if it's worth living. 2 I think of suicide or death several times a week for several minutes. 3 I think of suicide or death several times a day in some detail, or I have made specific plans for suicide or have actually tried to take my life. 13. General Interest: 0 There is no change from usual in how interested I am in other people or activities. 1 I notice that I am less interested in people or activities. 2 I find I have interest in only one or two of my formerly pursued activities. 3 I have virtually no interest in formerly pursued activities. 14. Energy Level: 0 There is no change in my usual level of energy. 1 I get tired more easily than usual. 2 I have to make a big effort to start or finish my usual daily activities (for example, shopping, homework, cooking or going to work). 3 I really cannot carry out most of my usual daily activities because I just don't have the energy. 15. Feeling slowed down: 0 I think, speak, and move at my usual rate of speed. 1 I find that my thinking is slowed down or my voice sounds dull or flat. 2 It takes me several seconds to respond to most questions and I'm sure my thinking is slowed. 3 I am often unable to respond to questions without extreme effort. 16. Feeling restless: 0 I do not feel restless. 1 I'm often fidgety, wringing my hands, or need to shift how I am sitting. 2 I have impulses to move about and am quite restless. 3 At times, I am unable to stay seated and need to pace around. To Score: 1. Enter the highest score on any 1 of the 4 sleep items (1-4) 2. Item 5 3. Enter the highest score on any 1 appetite/ weight item (6-9) 4. Item Item Item Item Item Enter the highest score on either of the 2 psychomotor items (15 and 16) TOTAL SCORE (Range 0-27)

13 National Network of Depression Centers Common Assessment Package: Self-Rated Patient Health Questionnaire (PHQ-9) Instructions: Please circle one number for each statement. Over the last 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself- or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. 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. 9. Thoughts that you would be better off dead, or of hurting yourself. Not at all Several days More than half the days Nearly every day 10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult PHQ-9 Copyright 1999 Pfizer Inc. All rights reserved. NNDC Common Assessment Package: Self-Rated (January 25, 2011)

14 National Network of Depression Centers Common Assessment Package: Self-Rated Generalized Anxiety Disorder Scale (GAD-7) Instructions: Please circle one number for each statement. Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several days More than half the days Nearly every day 1. Feeling nervous, anxious, or on edge 2. Not being able to stop or control worrying 3. Worrying too much about different things 4. Trouble relaxing 5. Being so restless it is hard to sit still 6. Becoming easily annoyed or irritable 7. Feeling afraid as if something awful might happen If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Intern Med 2006;166: Arch NNDC Common Assessment Package: Self-Rated (January 25, 2011)

15 National Network of Depression Centers Common Assessment Package: Self-Rated Altman Self-Rating Mania Scale (ASRM) Instructions: On this questionnaire are groups of 5 statements; read each group of statements carefully. Choose the one statement in each group that best describes the way you have been feeling for the past week. Circle the number next to the statement you picked. Please note: The word occasionally when used here means once or twice;; often means several times or more;; frequently means most of the time ) I do not feel happier or more cheerful than usual. 2) I occasionally feel happier or more cheerful than usual. 3) I often feel happier or more cheerful than usual. 4) I feel happier or more cheerful than usual most of the time. 5) I feel happier or more cheerful than usual all of the time. 1) I do not feel more self-confident than usual. 2) I occasionally feel more self-confident than usual. 3) I often feel more self-confident than usual. 4) I feel more self-confident than usual most of the time. 5) I feel extremely self-confident all of the time. 1) I do not need less sleep than usual. 2) I occasionally need less sleep than usual. 3) I often need less sleep than usual. 4) I frequently need less sleep than usual. 5) I can go all day or night without any sleep and still not feel tired. 1) I do not talk more than usual. 2) I occasionally talk more than usual. 3) I often talk more than usual. 4) I frequently talk more than usual. 5) I talk constantly and cannot be interrupted. 1) I have not been more active (either socially, sexually, at work, home or school) than usual. 2) I have occasionally been more active than usual. 3) I have often been more active than usual. 4) I have frequently been more active than usual. 5) I am constantly active or on the go all the time. NNDC Common Assessment Package: Self-Rated (January 25, 2011)

16 National Network of Depression Centers Common Assessment Package: Self-Rated (Baseline) Work and Social Adjustment Scale (WSAS) Instructions: Rate each of the following questions on a 0 to 8 scale: 0 indicates no impairment at all and 8 indicates very severe impairment. Please circle your responses below. 1. Because of my mood problems, my ability to work is impaired. 0 means not at all impaired and 8 means very severely impaired to the point I can t work Because of my mood problems, my home management (cleaning, tidying, shopping, cooking, looking after home or children, paying bills) is impaired. 0 means not at all impaired and 8 means very severely impaired Because of my mood problems, my social leisure activities (with other people, such as parties, bars, clubs, outings, visits, dating, home entertainment) are impaired. 0 means not at all impaired and 8 means very severely impaired Because of my mood problems, my private leisure activities (done alone, such as reading, gardening, collecting, sewing, walking alone) are impaired. 0 means not at all impaired and 8 means very severely impaired Because of my mood problems, my ability to form and maintain close relationships with others, including those I live with, is impaired. 0 means not at all impaired and 8 means very severely impaired Mundt, J.C., Marks, I.M., Shear, M.K., & Greist, J.H. (2002). The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br J Psychiatry, 180, NNDC Common Assessment Package, Baseline: Self-Rated (February 14, 2011)

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