Nurse Practitioner Information

Please correct the errors described below.

MEDICAL & PHYSICAL HISTORY

PREVIOUS BEHAVIORAL HEALTH TREATMENT

Physical Symptoms: 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

Current Depressive Symptoms: 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

Other Mood Symptoms: 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 have had an anxiety attack or panic attack in the last 2 weeks,

How's your Eating?

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

Substance Use History

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

Attentional/Behavioral Symptoms

Abuse/Trauma

FAMILY HISTORY

Social History

Developmental Milestones (for Kids 15 & Under)

OTHER

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