Health Management Screen
by Christian Laplante, Ph.D., R.Psych
Name
*
First Name
First and last letter of last name
Date
*
-
Year
-
Month
Day
Date
Instructions
For items 1 to 9, check 3 boxes representing your BEST, WORST and AVERAGE for each symptom in the past 7 days. N.B. If your average is identical to your best or worst answer, please select the next closest choice. If your symptom does not change at all, it is acceptable to have only one answer.
1
0 None
1
2
3
4
5
6
7
8
9
10 Extreme
1. Body pain intensity
2
3
4
5
6
7
8
9
10
11
12
2.
Headache pain intensity
13
14
15
16
17
18
19
20
21
22
23
3.
Stress level
24
25
26
27
28
29
30
31
32
33
34
4. Energy level
35
36
37
38
39
40
41
42
43
44
45
46
0
5
10
15
20
30
45
60
2hrs
3+ hrs
5. Time required to fall asleep (in minutes)
47
48
49
50
51
52
53
54
55
56
57
0
1
2
3
4
5
6
7
8
9
10+
6. Number of awakenings (per night)
58
59
60
61
62
63
64
65
66
67
68
7. Total duration of sleep (per night)
69
70
71
72
73
74
75
76
77
78
79
80
0 Terrible
1
2
3
4
5 Okay
6
7
8
9
10 Amazing
8. Mood
81
82
83
84
85
86
87
88
89
90
91
9. Ability to relax
92
93
94
95
96
97
98
99
100
101
102
103
0
10
20
30
40
50
60
70
80
90
100
10. Ability to do your job duties right now (%)
104
105
106
107
108
109
110
111
112
113
114
Submit
Should be Empty: