CalTMS - HAM-A + PHQ-9

1

First, please tell us your name.* This field is required.All information is securely stored and confidential.

First Name

Last Name

2

Your Cell Number* This field is required.Used to verify your health record

Please enter a valid phone number.

3

How would you rate your Anxious Mood?* This field is required.Please choose on a scale of 0 to 4 0 = Not present to 4 = Severe

4

Tension* This field is required.Please choose on a scale of 0 to 4 0 = Not present to 4 = Severe

5

Fears* This field is required.Please choose on a scale of 0 to 4 0 = Not present to 4 = Severe

6

Insomnia* This field is required.Please choose on a scale of 0 to 4 0 = Not present to 4 = Severe

7

Intellectual* This field is required.Please choose on a scale of 0 to 4 0 = Not present to 4 = Severe

8

Depressed Mood* This field is required.Please choose on a scale of 0 to 4 0 = Not present to 4 = Severe

9

Somatic Complaints: Muscular* This field is required.Please choose on a scale of 0 to 4 0 = Not present to 4 = Severe

10

Somatic Complaints: Sensory* This field is required.Please choose on a scale of 0 to 4 0 = Not present to 4 = Severe

11

Cardiovascular Symptoms* This field is required.Please choose on a scale of 0 to 4 0 = Not present to 4 = Severe

12

Respiratory Symptoms* This field is required.Please choose on a scale of 0 to 4 0 = Not present to 4 = Severe

13

Gastrointestinal Symptoms* This field is required.Please choose on a scale of 0 to 4 0 = Not present to 4 = Severe

14

Genitourinary Symptoms* This field is required.Please choose on a scale of 0 to 4 0 = Not present to 4 = Severe

15

Autonomic Symptoms* This field is required.Please choose on a scale of 0 to 4 0 = Not present to 4 = Severe

16

Over the past 2 weeks, how often have you experienced the following?* This field is required.Little interest or pleasure in doing things

Nearly every day

More than half the days

Several days

Not at all

17

Feeling down, depressed, or hopeless* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

18

Trouble falling or staying asleep, or sleeping too much* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

19

Feeling tired or having little energy* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

20

Poor appetite or overeating* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

21

Feeling bad about yourself...or that you are a failure or have let yourself or your family down* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

22

Trouble concentrating on things, such as reading, or watching television* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

23

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* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

24

Thoughts that you would be better off dead, or of hurting yourself* This field is required.Over the past 2 weeks, how often have you experienced the above?

Nearly every day

More than half the days

Several days

Not at all

25

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?* This field is required.Last question for the Depression Quiz.

Extremely difficult

Very difficult

Somewhat difficult

Not difficult at all

26

Results of your HAM-AThe Hamilton Anxiety Scale (13 questions) is designed for Anxiety

Out of 52. Based on HAM-A.

27

Results of your PHQ-9The Patient Health Questionnaire (9 questions) is designed for Depression

Out of 27. Based on PHQ-9.

28

Enter an email if you'd like a copy or click Submit.All information is secure and confidential.

example@example.com