Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol
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- Alexandra Scott
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1 PRE-EVALUATION FORM
2 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 Sudden death/arrthymia Suicide attempts ADHD Alcoholism Drug Abuse/Addiction Learning disability Legal Problems Schiozphrenia Stroke OCD PTSD Eating disorder Other: list below
3 General well-being Fever Weight loss (>10#) Weight gain (>10#) Excess fatigue Recurrent Nausea / vomit Night sweats Eyes Eye symptoms Visual Changes Ears, Nose, Mouth & Throat Hearing loss Pressure in ears Ringing in ears Pain in ears Balance disturbance Dizziness Nasal congestion Nosebleeds Sinus problems Difficulty swallowing Sore throats Respiratory Chronic cough Shortness of breath Snoring Wheezing Cardiovascular Chest pain Irregular heartbeat Heart murmur Exercise Intolerance Low blood pressure Arm and leg swelling Gastrointestinal Indigestion Nausea / vomiting Jaundice Abdominal pain Change in bowel habits Constipation Diarrhea Hematologic/ Lymphatic Anemia Easy bleeding / bruising Swollen glands Genitourinary/Breast Painful urination Blood in urine Difficulty urinating Incontinence Irregular menstrual cycles Unusual breast enlargement/tenderness Leakage from nipple Neurological Disorientation Fainting / blacking out Light headedness Memory problems Concentration problems
4 Neurologic continued Speech problems Facial weakness/ spasms Muscle weakness Coordination problems Uncontrolled shaking Headache Migraine Endocrine Increased appetite Excessive thirst Excessive urination Temperature intolerance Excessive sweating Immunologic Frequent colds / infections Skin Dry or scaling skin Rashes Changes in skin color Changes in moles Musculoskeletal Arm or leg weakness Joint pain or swelling Back pain How satisfied are you with your current job? Very unsatisfied Unsatisfied Satisfied Very satisfied 2. Has your current problem/concern affected your work? Yes / No
5
6 PATIENT HEALTH QUESTIONNAIRE (PHQ-9) Over the last 2 weeks, how often have you been More Nearly bothered by any of the following problems? Several than half every (Circle the number to indicate your answer) Not at all Days the days day 1. Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling or staying asleep or sleeping too much Feeling tired or having little energy Poor appetite or overeating 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 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? Thoughts that you would be better off dead or hurting yourself in some way FOR OFFICE CODING = Total Score 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 Please use this space to give details about any of the questions above. List the question number and your explanation: Page 6
7 GAD-7 Over the last 2 weeks, how often have you Several More than Nearly every been bothered by the following problems? Not at all Days half the day Circle the number for your answer days 1 Feeling nervous, anxious or on edge Not being able to stop or control worrying Worrying too much about different things Trouble relaxing Being so restless that it is hard to sit still Becoming easily annoyed or irritable Feeling afraid-as if something awful might happen For office coding: Total Score = + + 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 Please use the following space to give details about any of the questions above. List the question number and your explanation Page 7 J:\Intranet\Pre-Eval Forms and Info\GAD-7
8 AUDIT-C QUESTIONNAIRE PAGE 1 Please circle the answer that is correct for you 1. How often do you have a drink containing alcohol? or less 24 times a month 23 times a week 4 or more times a week 2. How many standard drinks containing alcohol do you have on a typical day when drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more 3. How often do you have six or more drinks on one occasion? 4. During the past year, how often have you found that you were not able to stop drinking once you had started? 5. During the past year, how often have you failed to do what was normally expected of you because of drinking? PAGE 8
9 AUDIT-C QUESTIONNAIRE PAGE 2 6. During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session? 7. During the past year, how often have you had a feeling of guilt or remorse after drinking? 8. During the past year, have you been unable to remember what happened the night before because you had been drinking? 9. Have you or someone else been injured as a result of your drinking? No Yes, but not in the past year Yes, during the past year 10. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down? No Yes, but not in the past year Yes, during the past year Please use the lines below to further explain any of the answers given above. Please reference the question number when giving your explanation. Page 8-A
10 DRUG USE QUESTIONNAIRE (DAST-10) The following questions concern information about your potential involvement with drugs excluding alcohol and tobacco during the past 12 months. Carefully read each statement and decide if your answer is NO or YES. Place an X in the appropriate column. When the words drug abuse are used, they mean the use of prescribed or over-the-counter in excess of the directions and any non-medical use of drugs. The various classes of drugs may include: cannabis (e.g., marijuana, hash), solvents, tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants, (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin. Remember that the questions do not include alcohol or tobacco. Please answer every questions. If you have difficulty with a statement, then choose the response that is mostly right. These questions refer to the past 12 months NO YES 1. Have you used drugs other than those required for medical reasons? 2. Do you abuse more than one drug at a time? 3. Are you always able to stop using drugs when you want to? 4. Have you had blackouts or flashbacks as a result of drug use? 5. Do you ever feel bad or guilty about your drug use? 6. Does your spouse (or parents) ever complain about your involvement with drugs? 7. Have you neglected your family because of your use of drugs? 8. Have you engaged in illegal activities in order to obtain drugs? 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 10. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)? Please use the lines below to further explain any of your answers given above. Please reference the question number with your explanation. Page 9
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