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🗨️ 412-569-4300
Menu
About
Contact
Screenings
Preferred Partner
Resources
Policies
What is buprenorphine?
FAQs
HIPAA
☏ 855-409-8855
🗨️ 412-569-4300
Phone
About
Contact
Screenings
Preferred Partner
Resources
Policies
What is buprenorphine?
FAQs
HIPAA
☏ 855-409-8855
🗨️ 412-569-4300
Menu
About
Contact
Screenings
Preferred Partner
Resources
Policies
What is buprenorphine?
FAQs
HIPAA
☏ 855-409-8855
🗨️ 412-569-4300
About
Contact
Screenings
Preferred Partner
Resources
Policies
What is buprenorphine?
FAQs
HIPAA
☏ 855-409-8855
🗨️ 412-569-4300
Menu
About
Contact
Screenings
Preferred Partner
Resources
Policies
What is buprenorphine?
FAQs
HIPAA
☏ 855-409-8855
🗨️ 412-569-4300
Mental Health Questionnaire
Mental Health Questionnaire
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press
Enter
Depression Questionnaire
Do you have Little interest or pleasure in doing things on a daily basis?
✅YES
❌NO
On a daily basis do you find yourself feeling down, depressed or hopeless?
✅YES
❌NO
Do you feel like your daily mood causes you trouble falling asleep, staying asleep, or sleeping too much?
*
✅YES
❌NO
In your opinion do you think you have low energy on a daily basis?
*
✅YES
❌NO
Does your mood sometimes cause poor appetite or overeating?
*
✅YES
❌NO
Do you Feel bad about yourself – or that you’re a failure and have let yourself and your family down on a regular basis?
*
✅YES
❌NO
Do you have thoughts that you would be better off dead or of hurting yourself in some way?
*
✅YES
❌NO
Which of these do you think describes your daily depression most accurately?
*
😐MILD
😕MODERATE
😒SEVERE
Anxiety Questionnaire
Do you Feel nervous, anxious or on edge on a daily basis?
*
✅YES
❌NO
Do you have trouble with being able to stop or control worrying?
*
✅YES
❌NO
Do you have issues worrying about too many different things at the same time?
*
✅YES
❌NO
Do you feel you have trouble relaxing on a daily basis?
*
✅YES
❌NO
Have you ever been so restless that it is hard to sit still?
*
✅YES
❌NO
Do you feel that your anxiety causes you headaches?
*
✅YES
❌NO
Are you easily annoyed or irritable?
*
✅YES
❌NO
Do you feel afraid something awful might happen on a daily basis?
*
✅YES
❌NO
Which of these do you feel describes your daily anxiety?
*
😐MILD
😕MODERATE
😒SEVERE
Last few questions (Don’t worry everything is confidential)
1: Are you currently abusing illicit substances?
*
✅YES
❌NO
2: Do you smoke cigarettes?
*
✅YES
❌NO
3: Do you currently suffer from Diabetes or Heart Disease?
*
✅YES
❌NO
4: Have you had a physical exam in the last 12 Months?
*
✅YES
❌NO
5: Is there anything you feel that our providers should know about prior to prescribing medications for your Anxiety or Depression?
*
✅YES
❌NO
6. Is there anything you feel that our providers should know about prior to prescribing medications for your Anxiety or Depression?
What is your FIRST NAME?
*
We will contact you using this name.
If you are human, leave this field blank.
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