AMS Psychiatry
Have you ever been hospitalized for psychiatric care? Please list and describe.
Have you ever been treated with any of the following medications? Circle all that apply and list any good or bad effects of the medications.
Abilify
Ambien
Adderall
Anafranil
Antabuse
Ascendin
Atarax
Ativan
Buspar
Campral
Celexa
Chloral hydrate
Clozaril
Cogentin
Concerta
Cymbalta
Dalmane
Depakote
Dexedrine
Doral
Effexor
Elavil
Fanapt
Geodon
Halcion
Haldol
Klonopin
Invega
Lamictal
Latuda
Lexapro
Librium
Lithium
Lunesta
Luvox
Marplan
Mellaril
Methadone
Miltown
Nardil
Norpramine
Orap
Pamelor
Parnate
Paxil
Prosom
Prolixin
Remeron
Restoril
Risperdal
Ritalin
Saphris
Serax
Seroquel
Serzone
Soma
Sonata
Stelazine
Strattera
Suboxone/subutex
Symmetrel
Tegretol
Thorazine
Tofranil
Topomax
Traxene
Trazodone
Trileptal
Valium
Vibryd
Vistraril
Vivitrol
Wellbutrin
Xanax
Zoloft
Zyprexa
Please list all medications you are currently taking, including over-the-counter medications, herbals, and supplements.
How often have you used the following substances?
Tobacco
Alcohol
Marijuana or K2/"spice"
Cocaine
Opiates (e.g. Heroin, morphine, Percocet, 5 oxycodone, Tylenol #3, Dilaudid/hydromorphone)
Tranquilizers/sedatives (e.g. Xanax, Ativan, Klonopin, Valium)
PCP or LSD
Mushrooms
Others
Please list blood relatives who have been diagnosed with the following conditions.
Over the last 2 weeks. how often have you been bothered by any of the following problems?
PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. For research information, contact Dr. Spitzer at rls8@columbia.edu. Use of the PHQ-9 may only be made in accordance with the Terms of Use available at http://www.pfizer.com.Copyright © 1999 Pfizerlnc.Allrightsreserved. PRIME MD TODAY is a trademark of Pfizer Inc.
ZT274388
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:
SCORE RESULTS:
Johns, M.W. (1991). A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep, 14, 540-545. Permission for single-use of the information contained in this material was obtained from the Associated Professional Sleep Societies, LLC, September 2006.
Copyright © MW Johns 1990-1997. Used under license.
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