FORM-Health Questionnaire Patient Health Questionnaires These questionnaires must only be completed by patients ages 16 and older. Patient Name(Required) First Last Date of Birth(Required) Email(Required) Over the last two weeks, how often have you been bothered by any of the following issues?1. Little interest or pleasure in doing things(Required) Not at all Several days More than half the days Nearly every day 2. Feeling down, depressed, or hopeless(Required) Not at all Several days More than half the days Nearly every day 3. Trouble falling asleep, staying asleep, or sleeping too much(Required) Not at all Several days More than half the days Nearly every day 4. Feeling tired or having little energy(Required) Not at all Several days More than half the days Nearly every day 5. Poor appetite or overeating(Required) Not at all Several days More than half the days Nearly every day 6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down(Required) Not at all Several days More than half the days Nearly every day 7. Trouble concentrating on things, such as reading the newspaper or watching television(Required) Not at all Several days More than half the days Nearly every day 8. 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(Required) Not at all Several days More than half the days Nearly every day 9. Thoughts that you would be better off dead, or of hurting yourself in some way(Required) Not at all Several days More than half the days Nearly every day If you were bothered by any of the above, how difficult have these issues made it for you to do your work, take care of things at home, or get along with others?(Required) Not Difficult Somewhat Difficult Very Difficult Extremely Difficult 1. Has there been a period of time when you were not your usual self and…… you felt so good or hyper that other people thought you were not your normal self, or you were so hyper you got into trouble? Yes No … you were so irritable that you shouted at other people, or stated fights or arguments? Yes No … you felt much more self-confident than usual? Yes No … you got much less sleep than usual and found you didn't really miss it? Yes No … you were much more talkative or spoke much faster than usual? Yes No … thoughts raced through your head, or you couldn't slow your mind down? Yes No … you were so easily distracted by things around you that you had trouble concentrating or staying on track? Yes No … you had much more energy than usual? Yes No … you were much more active or did many more things than usual? Yes No … you were much more social or outgoing than usual; for example, you telephoned friends in the middle of the night? Yes No … you were much more interested in sex than usual? Yes No … you did things that were unusual for you, or that other people might have thought were excessive, foolish, or risky? Yes No … spending money got you or your family in trouble? Yes No 2. If you have checked YES to more than one of the above, have several of these ever happened during the same period of time? Yes No 3. How much of a problem did any of these cause you – like being unable to work; having family or legal troubles; getting into arguments or fights? No problem Minor problem Moderate problem Serious problem 4. Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder? Yes No 5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? Yes No EmailThis field is for validation purposes and should be left unchanged. Δ
