questionnaires - Tailored Psychiatric Wellness

Tailored Psychiatric Wellness Patient Questionnaires

Step 1 of 8 About you

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About you

So we can match these questionnaires to your file.

Legal first name *

Legal last name *

Date of birth *

Mobile phone *

Email *

Insurance

Have your insurance card handy. Please do not enter card or bank numbers.

Will you be using insurance? *

YesNo, I will self-pay

Primary insurance details

Insurance type *

MedicareMedicaidTRICARE / CHAMPUSCHAMPVAGroup health planFECA Black LungOther

Other insurance type (optional)

Insurance plan or program name *

Member ID *

Insurance company name (payer name) *

Payer ID *

Usually on the back of your card. Type "Unknown" if you can't find it.

Payer address (optional)

Payer city (optional)

Payer state (optional)

Payer ZIP code (optional)

Payer country (optional)

Policy group / FECA number (optional)

Valid from (optional)

Valid until (optional)

Copay (optional)

Deductible (optional)

Employer / school name (optional)

Comments (optional)

Insured person (policy holder)

Your relationship to the insured person *

Self (I am the policy holder)SpouseChildOther

Insured first name *

Insured last name *

Insured date of birth *

Insured sex *

MaleFemaleUnknown

Address line 1 (optional)

Address line 2 (optional)

City (optional)

State (optional)

ZIP code (optional)

Country (optional)

Home phone (optional)

Mobile phone (optional)

Anxiety (GAD-7)

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

1. Feeling nervous, anxious or on edge *

Not at allSeveral daysMore than half the daysNearly every day

2. Not being able to stop or control worrying *

Not at allSeveral daysMore than half the daysNearly every day

3. Worrying too much about different things *

Not at allSeveral daysMore than half the daysNearly every day

4. Trouble relaxing *

Not at allSeveral daysMore than half the daysNearly every day

5. Being so restless that it is hard to sit still *

Not at allSeveral daysMore than half the daysNearly every day

6. Becoming easily annoyed or irritable *

Not at allSeveral daysMore than half the daysNearly every day

7. Feeling afraid as if something awful might happen *

Not at allSeveral daysMore than half the daysNearly every day

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? *

Not difficult at allSomewhat difficultVery difficultExtremely difficult

Mood (MDQ)

Has there ever been a period of time when you were not your usual self and...

1. you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble? *

YesNo

2. you were so irritable that you shouted at people or started fights or arguments? *

YesNo

3. you felt much more self-confident than usual? *

YesNo

4. you got much less sleep than usual and found you really didn't miss it? *

YesNo

5. you were much more talkative or spoke much faster than usual? *

YesNo

6. thoughts raced through your head or you couldn't slow your mind down? *

YesNo

7. you were so easily distracted by things around you that you had trouble concentrating or staying on track? *

YesNo

8. you had much more energy than usual? *

YesNo

9. you were much more active or did many more things than usual? *

YesNo

10. you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? *

YesNo

11. you were much more interested in sex than usual? *

YesNo

12. you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? *

YesNo

13. spending money got you or your family into trouble? *

YesNo

A few more questions

Have several of these ever happened during the same time period? (optional)

YesNo

How much of a problem did any of these cause you - like being unable to work; having family, money or legal troubles; getting into arguments or fights? *

No problemMinor problemModerate problemSerious problem

Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder? *

YesNo

Has a professional ever told you that you have manic-depressive illness or bipolar disorder? *

YesNo

Stress (PCL-5)

In the past month, how much were you bothered by the following problems?

1. Repeated, disturbing, and unwanted memories of the stressful experience? *

Not at allA little bitModeratelyQuite a bitExtremely

2. Repeated, disturbing dreams of the stressful experience? *

Not at allA little bitModeratelyQuite a bitExtremely

3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)? *

Not at allA little bitModeratelyQuite a bitExtremely

4. Feeling very upset when something reminded you of the stressful experience? *

Not at allA little bitModeratelyQuite a bitExtremely

5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)? *

Not at allA little bitModeratelyQuite a bitExtremely

6. Avoiding memories, thoughts, or feelings related to the stressful experience? *

Not at allA little bitModeratelyQuite a bitExtremely

7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)? *

Not at allA little bitModeratelyQuite a bitExtremely

8. Trouble remembering important parts of the stressful experience? *

Not at allA little bitModeratelyQuite a bitExtremely

9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)? *

Not at allA little bitModeratelyQuite a bitExtremely

10. Blaming yourself or someone else for the stressful experience or what happened after it? *

Not at allA little bitModeratelyQuite a bitExtremely

11. Having strong negative feelings such as fear, horror, anger, guilt, or shame? *

Not at allA little bitModeratelyQuite a bitExtremely

12. Loss of interest in activities that you used to enjoy? *

Not at allA little bitModeratelyQuite a bitExtremely

13. Feeling distant or cut off from other people? *

Not at allA little bitModeratelyQuite a bitExtremely

14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)? *

Not at allA little bitModeratelyQuite a bitExtremely

15. Irritable behavior, angry outbursts, or acting aggressively? *

Not at allA little bitModeratelyQuite a bitExtremely

16. Taking too many risks or doing things that could cause you harm? *

Not at allA little bitModeratelyQuite a bitExtremely

17. Being "superalert" or watchful or on guard? *

Not at allA little bitModeratelyQuite a bitExtremely

18. Feeling jumpy or easily startled? *

Not at allA little bitModeratelyQuite a bitExtremely

19. Having difficulty concentrating? *

Not at allA little bitModeratelyQuite a bitExtremely

20. Trouble falling or staying asleep? *

Not at allA little bitModeratelyQuite a bitExtremely

Attention (ADHD), part 1

Please check every item below, indicating the degree to which the behavior is characteristic of yourself or the adult you are rating.