Dr. Gerald B Harris, II

Available Forms

Consent/Release Form Contract for Long-Term Controlled Substances Therapy for Chronic Pain and/or Dependence/Addiction Financial Policy Insurance Information New Patient - Registration New Patient - System Review Referral Form Weekly Blood Pressure Log Well-Woman Exam New Patient - Health History Questionnaire New patient - Alcohol Screening Test New patient - Depression Screening Pain Assessment New patient - Drug Abuse Screening Test (DAST) Therapy Progress Report Well Man Exam

New patient - Depression Screening

Patient Name *

First and Last Name

Date of Birth *

Date *

Over the past 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 asleep, 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 your're 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 oppisite - 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 *

10. Please notice that each of the above answers have a number assigned with each response. Please add these numbers together and write their total *

If you have any of the above problems, how difficult have those problems made it for you to do you work, take care of things at home, or get along with other people? *

My total was zero

Not difficult at all

Somewhat difficult

Very Difficult

Extremely difficult

* Required field