PsyCare

The following assessments should be completed by the patient if they are 17 years old:

PATIENT HEALTH QUESTIONNAIRE (PHQ-SADS)

This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every question to the best of your ability

A. During the last 4 weeks, how much have you been bothered by any of the following problems?

1. Stomach pain 2. Back pain 3. Pain in your arms, legs, or joints (knees, hips, etc.) 4. Feeling tired or having little energy 5. Trouble falling or staying asleep, or sleeping too much 6. Menstrual cramps or other problems with your periods 7. Pain or problems during sexual intercourse 8. Headaches 9. Chest pain 10. Dizziness 11. Fainting spells 12. Feeling your heart pound or race 13. Shortness of breath 14. Constipation, loose bowels, or diarrhea 15. Nausea, gas, or indigestion

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

1. Feeling nervous anxiety 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

C. Questions about anxiety attacks.

a. In the last 4 weeks, have you had an anxiety attack ? suddenly feeling fear or panic? b. Has this ever happened before? c. Do some of these attacks come suddenly out of the blue ? that is, in situations where you don?t expect to be nervous or uncomfortable? d. Do these attacks bother you a lot or are you worried about having another attack? e. During your last bad anxiety attack, did you have symptoms Like shortness of breath, sweating, or your heart racing, pounding or skipping?

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

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 of or hurting yourself in some way E. If you checked off any problems on this questionnaire, 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?

COLUMBIA IMPAIRMENT SCALE - YOUTH VERSION

Please circle the number that you think best describes the child or youth?s situation:

In general, how much of a problem do you think you have with:

1) getting into trouble? 2) getting along with your mother/mother figure? 3) getting along with your father/father figure? 4) feeling unhappy or sad?

How much of a problem would you say you have:

5) with your behavior at school? 6) with having fun? 7) getting along with adults other than (your mother and/or your father)?

How much of a problem do you have:

8) with feeling nervous or afraid? 9) getting along with your sister(s) and/or brother(s) 10) getting along with other kids your age?

How much of a problem would you say you have:

11) getting involved in activities like sports or hobbies? 12) with your school work (doing your job)? 13) with your behavior at home?