Client Health Questionnaire

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

Rows	Not at all-0	Several Days-1	More than half the days-2	Nearly every day-3
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
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
9. Thoughts that you would be better off dead, or of hurting yourself in some way

Add Columns for Totals
Several Days = 1 point ea
More than half the days = 2 points ea
Nearly every day = 3 points ea
Total: 0/ 27
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? (put a 1 in the box that best fits your answer, and a 0 in all other boxes)
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Total: 0/ 1

Alcohol Screening Questionnaire (AUDIT)
Drinking alcohol can affect your health and some medications you may take. Please help us provide you with the best medical care by answering the questions below.
Name
First NameLast Name
Date
MonthDayYear
Date

One drink equals: 12 oz. beer 5 oz. wine 1.5 oz. liquor (one shot)

Rows	Never-0	Monthly or less-1	2-4 times a month-2	2-3 times a week-3	4 or more times a week-4
1. How often do you have a drink containing alcohol?
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
3. How often do you have five or more drinks on one occasion?
4. How often during the last year have you found that you were not able to stop drinking once you had started?
5. How often during the last year have you failed to do what was normally expected of you because of drinking?
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
8. How often during the last year have you been unable to remember what happened the night before because of your drinking?
9. Have you or someone else been injured because of your drinking?
10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

Rows	Not at all-0	Several Days-1	More than half the days-2	Nearly every day-3
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

Rows	No	Yes
1. Have you ever used drugs other than those required for medical reasons?
2. Do you abuse more than one drug at a time?
3. Are you able to stop using drugs when you want to?
4. Have you ever had blackouts or flashbacks as a result of drug use?
5. Do you ever feel bad or guilty about your drug use?
6. Does your spouse (or parents) ever complain about your involvement with drugs?
7. Have you neglected your family because of your use of drugs?
8. Have you engaged in illegal activities in order to obtain drugs?
9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
10. Have you have medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?

Patient Health Questionnaire (PHQ9)