Tranquility Behavioral Health Patient Portal

Patient Health Questionnaire (PHQ-9)

Full Name: * Date of Birth *

Please select the option that best describes you.

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 or of hurting yourself in some way *

For Office Coding:

Total Score of 1's + Total Score of 2's + Total Score of 3's = Total Overall Score

If you checked off any problems, 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?

Select the one that applies *

Generalized Anxiety Disorder 7-item (GAD-7) scale

1. Feeling nervous, anxious 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 Total Score

Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097.

THE MOOD DISORDER QUESTIONNAIRE

1. 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 got into trouble? 2. you were so irritable that you shouted at people or started fights or arguments? 3. You felt much more self-confident than usual? 4. You got much less sleep than usual and found you didn't really miss it? 5. You were much more talkative or spoke much faster than usual? 6. Thoughts raced through your head or you couldn't slow your mind down? 7. You were so easily distracted by things around you that you had trouble concentrating or staying on track? 8. You had much more energy than usual? 9. You were much more active or did many more things than usual? 10. You were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? 11. You were much more interested in sex than usual? 12. You did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? 13. Spending money got you or your family into trouble? If you checked YES to more than one of the above, have several of these ever happened during the same period of time? * 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 check one response only. Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder? Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? INITIAL * * DATE SIGNED * Patient/Guardian Initial

Tranquility Behavioral Health Abnormal Movement Questionnaire

Patient First & Last Name * * D.O.B. * *

Are you having any body movements you can't control? Have others noticed or commented on particular movements? Please select a description of the movements from the options below.

If the section does not apply, please input N/A in the allotted space.

HEAD/ FACE If OTHER was selected, please describe UPPER LIMBS If OTHER was selected, please describe TORSO If OTHER was selected, please describe

ASSESS IMPACT

Have these movements impacted your daily routine? For example, while you are doing things like eating, walking, talking, or typing?o How have these movements bothered you? Do you experience embarrassment or isolation because of them? IF YES, PLEASE DESCRIBE If YES, please describe

THINK

When did you first noticed these movements, what did you think of them? * Have other people noticed your movements? What do you think they think is happening?

FEEL

How do the movements make you feel? *

ACT

How do the movements make you act? * Have these movements impacted your daily routine? lf so, how? * Patient/Guardian Initials * DATE: *

Abnormal Movement Questionnaire will be submitted to Gero-Psychiatric & Behavioral Health Consultants LLC DBA Tranquility Behavioral health LLC