• Date of Birth*
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  • Today
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  • SUBSTANCE ABUSE & MENTAL HEALTH SCREENING TOOL

    SAMHST
  • Over the last 2 weeks, how often have you been bothered by any of the following problems?
    Rows

  • Now I am going to ask you some questions about your use of alcoholic beverages during this past year.

  • How often do you have a drink containing alcohol?*
  • How many drinks containing alcohol do you have on a typical day when you are drinking?
  • How often do you have five or more drinks on one occasion?
  • How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?*
  • In the past year, have you been hit, kicked, punched, or otherwise hurt by someone?*
  • Over the last 2 weeks, how often have you been bothered by any of the following problems?
    Rows

  • STAYING HEALTHY ASSESSMENT

    ADULT

  • Please answer all the questions on this form as best you can. Mark “Skip” if you do not know an answer or do not wish to answer. Be sure to talk to the doctor if you have questions about anything on this form. Your answers will be protected as part of your medical record.

  • 1. Do you drink or eat 3 servings of calcium-rich foods daily, such as milk, cheese, yogurt, soy milk, or tofu?*
  • 2. Do you eat fruits and vegetables every day?*
  • 3. Do you limit the amount of fried food or fast food that you eat?*
  • 4. Are you easily able to get enough healthy food?*
  • 5. Do you drink a soda, juice drink, sports or energy drink most days of the week?*
  • 6. Do you often eat too much or too little food?*
  • 7. Are you concerned about your weight?*
  • 8. Do you exercise or spend time doing activities, such as walking, gardening, swimming for 1/2 hours a day?*
  • 9. Do you feel safe where you live?*
  • 10. Have you had any car accidents lately?*
  • 11. Have you been hit, slapped, kicked, or physically hurt by someone in the last year?*
  • 12. Do you always wear a seat belt when driving or riding a car?*
  • 13. Do you keep a gun in your house or place where you live?*
  • 14. Do you brush and floss your teeth daily?*
  • 15. Do you often feel sad, hopeless, angry, or worried?*
  • 16. Do you often have trouble sleeping?*
  • 17. Do you smoke or chew tobacco?*
  • 18. Do friends or family members smoke in your house or place where you live?*
  • 19. Do you drink 4 or more alcoholic drinks per day?*
  • 20. Do you use any drugs or medicines to help you sleep, relax, calm down, feel better, or lose weight?*
  • 21. Do you think you or your partner could be pregnant?*
  • 22. Do you think you or your partner could have a sexually transmitted infection (STI), such as Chlamydia, Gonorrhea, genital warts, etc.?*
  • 23. Have you or your partner(s) had sex without using birth control in the past year?*
  • 24. Have you or your partner(s) had sex with other people in the past year?*
  • 25. Have you or your partner(s) had sex without a condom in the past year?*
  • 26. Have you ever been forced or pressured to have sex?*
  • 27. Do you have other questions or concerns about your health?*

  • STAYING HEALTHY ASSESSMENT

    SENIOR

  • Please answer all the questions on this form as best you can. Mark “Skip” if you do not know an answer or do not wish to answer. Be sure to talk to the doctor if you have questions about anything on this form. Your answers will be protected as part of your medical record.

  • 1. Do you drink or eat 3 servings of calcium-rich foods daily, such as milk, cheese, yogurt, soy milk, or tofu?*
  • 2. Do you eat fruits and vegetables every day?*
  • 3. Do you limit the amount of fried food or fast food that you eat?*
  • 4. Are you easily able to get enough healthy food?*
  • 5. Do you drink a soda, juice drink, sports or energy drink most days of the week?*
  • 6. Do you often eat too much or too little food?*
  • 7. Do you have difficulty chewing or swallowing?*
  • 8. Are you concerned about your weight?*
  • 9. Do you exercise or spend time doing activities, such as walking, gardening, swimming for 1/2 hours a day?*
  • 10. Do you feel safe where you live?*
  • 11. Do you often have trouble keeping track of your medicines?*
  • 12. Are family members or friends worried about your driving?*
  • 13. Have you had any car accidents lately?*
  • 14. Do you sometimes fall and hurt yourself, or is it hard to get up?*
  • 15. Have you been hit, slapped, kicked, or physically hurt by someone in the last year?*
  • 16. Do you keep a gun in your house or place where you live?*
  • 17. Do you brush and floss your teeth daily?*
  • 18. Do you often feel sad, hopeless, angry, or worried?*
  • 19. Do you often have trouble sleeping?*
  • 20. Do you or others think that you are having trouble remembering things?*
  • 21. Do you smoke or chew tobacco?*
  • 22. Do friends or family members smoke in your house or place where you live?*
  • 23. In the past year, have you had 4 or more alcohol drinks in one day?*
  • 24. Do you use any drugs or medicines to help you sleep, relax, calm down, feel better, or lose weight?*
  • 25. Do you think you or your partner could have a sexually transmitted infection (STI), such as Chlamydia, Gonorrhea, genital warts, etc.?*
  • 26. Have you or your partner(s) had sex with other people in the past year?*
  • 27. Have you or your partner(s) had sex without a condom in the past year?*
  • 28. Have you ever been forced or pressured to have sex?*
  • 29. Do you have someone to help you make decisions about your health and medical care?*
  • 30. Do you need help bathing, eating, walking, dressing, or using the bathroom?*
  • 31. Do you have someone to call when you need help in an emergency?*
  • 32. Do you have other questions or concerns about your health?*
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