Adult Questionnaires Home Adult Questionnaires Please enable JavaScript in your browser to complete this form.Email *(GAD-7)Over the last 2 weeks, how often have you been bothered by any of the following problems?1 Feeling nervous, anxious or on edge0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day2 Not being able to stop or control worrying0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day3 Worrying too much about different things0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day4 Trouble relaxing0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day5 Being so restless that it is hard to sit stil0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day6 Becoming easily annoyed or irritable0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day7 Feeling afraid as if something awful might happen0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every dayPlease add up your total score from the GAD-7 questions above(PHQ-9)Over the last 2 weeks, how often have you been bothered by any of the following problems?1 Little interest or pleasure in doing things0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day2 Feeling down, depressed, or hopeless0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day3 Trouble falling or staying asleep, or sleeping too much0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day4 Feeling tired or having little energy0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day5 Poor appetite or overeating0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day6 Feeling bad about yourself — or that you are a failure or have let yourself or your family down0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day7 Trouble concentrating on things, such as reading the newspaper or watching television0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day8 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 0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day9 Thoughts that you would be better off dead or of hurting yourself in some way 0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every dayPlease add up your total score from the PHQ-9 questions aboveMood Disorder Questionnaire1. Has there ever been a period of time when you were not your usual self and......you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you go into trouble? YesNo...you were so irritable that you shouted at people or started fights or arguments? YesNo...you felt much more self-confident than usual? YesNo...you got much less sleep than usual and found that you didn’t really miss it? YesNo...you were much more talkative or spoke much faster than usual? YesNo...thoughts raced through your head or you couldn’t slow your mind down? YesNo...you were so easily distracted by things around you that you had trouble concentrating or staying on track? YesNo...you had much more energy than usual? YesNo...you were much more active or did many more things than usual? YesNo...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? YesNo...you were much more interested in sex than usual? YesNo...you did things that were unusual for you or that other people might have Thought were excessive, foolish or risky? YesNo...spending money got you or your family into trouble? YesNo2. If you checked YES to more than one of the boxes above, have several of these ever happened during the same period of time?YesNo3. How much of a problem did any of these cause you – like being unable to work; having family, money or legal troubles; getting into arguments or fights? Please select one response only.No ProblemMinor ProblemModerate ProblemSerious problem4. Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?YesNo5. Has a health professional ever told you that you have manic-depressive illness or Bipolar disorder?YesNoPatient Name *Submit Adult Questionnaires Home Adult Questionnaires Please enable JavaScript in your browser to complete this form.Email *(GAD-7)Over the last 2 weeks, how often have you been bothered by any of the following problems?1 Feeling nervous, anxious or on edge0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day2 Not being able to stop or control worrying0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day3 Worrying too much about different things0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day4 Trouble relaxing0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day5 Being so restless that it is hard to sit stil0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day6 Becoming easily annoyed or irritable0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day7 Feeling afraid as if something awful might happen0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every dayPlease add up your total score from the GAD-7 questions above(PHQ-9)Over the last 2 weeks, how often have you been bothered by any of the following problems?1 Little interest or pleasure in doing things0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day2 Feeling down, depressed, or hopeless0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day3 Trouble falling or staying asleep, or sleeping too much0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day4 Feeling tired or having little energy0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day5 Poor appetite or overeating0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day6 Feeling bad about yourself — or that you are a failure or have let yourself or your family down0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day7 Trouble concentrating on things, such as reading the newspaper or watching television0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day8 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 0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every day9 Thoughts that you would be better off dead or of hurting yourself in some way 0, Not at all1, Several daysThird Choice 2, More than half the days3, Nearly every dayPlease add up your total score from the PHQ-9 questions aboveMood Disorder Questionnaire1. Has there ever been a period of time when you were not your usual self and......you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you go into trouble? YesNo...you were so irritable that you shouted at people or started fights or arguments? YesNo...you felt much more self-confident than usual? YesNo...you got much less sleep than usual and found that you didn’t really miss it? YesNo...you were much more talkative or spoke much faster than usual? YesNo...thoughts raced through your head or you couldn’t slow your mind down? YesNo...you were so easily distracted by things around you that you had trouble concentrating or staying on track? YesNo...you had much more energy than usual? YesNo...you were much more active or did many more things than usual? YesNo...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? YesNo...you were much more interested in sex than usual? YesNo...you did things that were unusual for you or that other people might have Thought were excessive, foolish or risky? YesNo...spending money got you or your family into trouble? YesNo2. If you checked YES to more than one of the boxes above, have several of these ever happened during the same period of time?YesNo3. How much of a problem did any of these cause you – like being unable to work; having family, money or legal troubles; getting into arguments or fights? Please select one response only.No ProblemMinor ProblemModerate ProblemSerious problem4. Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?YesNo5. Has a health professional ever told you that you have manic-depressive illness or Bipolar disorder?YesNoPatient Name *Submit
