Initial Assessments

 

Patient Full Name:
Date of visit:


Patient Health Questionnaire (PHQ-9)

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
    0. Not at all1. Several days2. More than half the days3. Nearly every day
  2. Feeling down, depressed, or hopeless
    0. Not at all1. Several days2. More than half the days3. Nearly every day
  3. Trouble falling or staying asleep, or sleeping too much
    0. Not at all1. Several days2. More than half the days3. Nearly every day
  4. Feeling tired or having little energy
    0. Not at all1. Several days2. More than half the days3. Nearly every day
  5. Poor appetite or overeating
    0. Not at all1. Several days2. More than half the days3. Nearly every day
  6. Feeling bad about yourself — or that you are a failure or
    have let yourself or your family down
    0. Not at all1. Several days2. More than half the days3. Nearly every day
  7. Trouble concentrating on things, such as reading the newspaper or watching television
    0. Not at all1. Several days2. More than half the days3. Nearly every day
  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
    0. Not at all1. Several days2. More than half the days3. Nearly every day
  9. Thoughts that you would be better off dead or of hurting yourself in some way
    0. Not at all1. Several days2. More than half the days3. Nearly every day

 


General Anxiety Disorder (GAD-7)

Over the last 2 weeks, how often have you been bothered by the following problems?

  1. Feeling nervous, anxious or on edge
    0. Not at all1. Several days2. More than half the days3. Nearly every day
  2. Not being able to stop or control worrying
    0. Not at all1. Several days2. More than half the days3. Nearly every day
  3. Worrying too much about different things
    0. Not at all1. Several days2. More than half the days3. Nearly every day
  4. Trouble relaxing
    0. Not at all1. Several days2. More than half the days3. Nearly every day
  5. Being so restless that it is hard to sit still
    0. Not at all1. Several days2. More than half the days3. Nearly every day
  6. Becoming easily annoyed or irritable
    0. Not at all1. Several days2. More than half the days3. Nearly every day
  7. Feeling afraid as if something awful might happen
    0. Not at all1. Several days2. More than half the days3. Nearly every day

 


SBQ-R Suicide Behaviors Questionnaire-Revised

Please check the number beside the statement or phrase that best applies to you.

  1. Have you ever thought about or attempted to kill yourself?

  2. How often have you thought about killing yourself in the past year?

  3. Have you ever told someone that you were going to commit suicide, or that you might do it?

  4. How likely is it that you will attempt suicide someday?


 


CAGE-AID Questionnaire

When thinking about drug use, include illegal drug use and the use of prescription drug use other than prescribed.

  1. Have you ever felt that you ought to cut down on your drinking or drug use?
    YesNo
  2. Have people annoyed you by criticizing your drinking or drug use?
    YesNo
  3. Have you ever felt bad or guilty about your drinking or drug use?
    YesNo
  4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
    YesNo

 


Adverse Childhood Experience (ACE) Questionnaire

While you were growing up, during your first 18 years of life:

  1. Did a parent or other adult in the household often ...

    Swear at you, insult you, put you down, or humiliate you?

    or

    Act in a way that made you afraid that you might be physically hurt?

    YesNo

  2. Did a parent or other adult in the household often ...

    Push, grab, slap, or throw something at you?

    or

    Ever hit you so hard that you had marks or were injured?

    YesNo

  3. Did an adult or person at least 5 years older than you ever...

    Touch or fondle you or have you touch their body in a sexual way?

    or

    Try to or actually have oral, anal, or vaginal sex with you?

    YesNo

  4. Did you often feel that ...

    No one in your family loved you or thought you were important or special?

    or

    Your family didn’t look out for each other, feel close to each other, or support each other?

    YesNo

  5. Did you often feel that ...

    You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?

    or

    Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

    YesNo

  6. Were your parents ever separated or divorced?

    YesNo

  7. Was your mother or stepmother:

    Often pushed, grabbed, slapped, or had something thrown at her?

    or

    Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?

    or

    Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

    YesNo

  8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
    YesNo
  9. Was a household member depressed or mentally ill or did a household member attempt suicide?
    YesNo
  10. Did a household member go to prison?
    YesNo



 

 

This is the end of your assessments. If you clicked the SUBMIT button above and received the confirmation message, inform your therapist.