Adult Behavioral Health Information

Please correct the errors described below.

3. In the last 4 weeks, have often have you been bothered by the following:

For the following questions, please indicate a

  • 0 Not Bothered At All
  • 1 Bothered a Little
  • 2 Bothered a Lot

4. Over the last 2 weeks, how often have you been bothered by any of the following problems? For the following questions, please indicate if you have experienced these problems--

  • 0 Not at All
  • 1 Several Days
  • 2 More than Half the Days
  • 3 Nearly Every Day

5. Have you been bothered by any of the following problems for at least one week? For the following issues, please use the following scale.

  • 0 Not at all
  • 1 Several Days
  • 2 More than Half the Days
  • 3 Nearly Every Day

Anxiety

If you answered "No" to question #6, skip to Question #9.

7. If you have had an anxiety attack or panic attack in the last 2 weeks,

8. If you have had panic attacks, think about your last panic attack

If you answered "Not at all" to question #9, SKIP to question #11

10. Over the last 4 weeks, how often have you been bothered by any of the following problems. Use the scale below

  • 0 Not at all
  • 1 Several Days
  • 2 More than Half the Days

11. How's your Eating?

13. In the last 3 months have you often done any of the following in order to avoid gaining weight?

Alcohol Use

16. Have any of the following happened to you more than once in the last 6 months?

MEDICAL & PHYSICAL HISTORY

PREVIOUS BEHAVIORAL HEALTH TREATMENT

FAMILY HISTORY

OTHER

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