Skagit Pediatrics ONLINE Well Adolescent Intake (12-21yrs)

Patient's Name:

Today's Date:

Birth date:

(MM/DD/YYYY)

Age:

We look forward to seeing you at your visit.

To give you the best possible health care, we would like to know how things are going. Our discussions with you are private. Information is not shared with other people without your permission unless we are concerned that someone might be in danger. We hope you will feel free to talk openly with us.

Please complete this form and click submit. We will receive it in a safe and confidential way.

What questions or concerns would you like to discuss at your visit?

Patient Health Questionnaire

Instructions: How often have you been bothered by each of the following symptoms DURING THE PAST TWO WEEKS?

For each symptom put an “X” in the box beneath the answer that best describes how you have been feeling.

1. Feeling down, depressed, or hopeless?

0 Not At All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

2. Little interest or pleasure in doing things?

0 Not At All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

3. Trouble falling asleep, or sleeping too much?

0 Not At All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

4. Poor appetite, weight loss, or overeating?

0 Not At All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

5. Feeling tired or having little energy?

0 Not At All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

6. Feeling bad about yourself - or that you are a failure or that you have let yourself or your family down?

0 Not At All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

Trouble concentrating on things, like schoolwork, reading, or watching TV?

0 Not At All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

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 All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

Thoughts that you would be better off dead or hurting yourself in some way?

0 Not At All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

In the PAST YEAR, have you felt depressed or sad most days, even if you felt okay sometimes:

Yes No

If you are experiencing any of the problems on this form, how difficult have the 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

Has there been a time in the past month where you have had serious thoughts about ending your life?

Yes No

Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?

Yes No

GAD-7

Over the last two weeks, how often have you been bothered by the following problems? For each symptom, select the answer that best describes how you have been feeling.

1. Feeling nervous, anxious, or on edge

0 Not At All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

2. Not being able to stop or control worrying

0 Not At All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

3. Worrying too much about different things

0 Not At All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

4. Trouble relaxing

0 Not At All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

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

0 Not At All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

6. Becoming easily annoyed or irritable

0 Not At All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

7. Feeling afraid, as if something awful might happen

0 Not At All 1 Several Days 2 More than Half of the Days 3 Nearly Every Day

If you checked any problems, how difficult have they 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

In the PAST YEAR, how many times have you used:

Tobacco/Nicotine?

Never Once or Twice Monthly Weekly

Alcohol?

Never Once or Twice Monthly Weekly

Marijuana?

Never Once or Twice Monthly Weekly

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