M.T. Curry Inc - Publicforms

Available Forms

12 Month Wellness Exam 12 Month Wellness Exam Spanish 18 Month Wellness Exam 18 Month Wellness Exam Spanish 24 Month Wellness Exam 24 Month Wellness Exam Spanish 3-21 Year Wellness Exam 3-21 Year Wellness Exam Spanish ACT 12 years and older ACT 12 years and older Spanish ACT 4 to 11 years ACT 4 to 11 years Spanish ADHD Agreement ADHD Agreement Spanish Adult ADHD Self-Report Scale Adult ADHD Self-Report Scale Spanish Conner's Pediatric Conner's Pediatric Spanish COVID-19 Screening English COVID-19 Screening Spanish 2 Family Medical History Family Medical History Spanish Flu Quest 2020 Flu Quest 2020 Spanish HIPAA 18yr HIPAA 18yr Spanish Interview & Lunch Rep COVID-19 Screening New Patient Registration New Patient Registration Spanish Newborn Insurance Waiver Newborn Insurance Waiver Spanish PHQ-9 and GAD (Patient Health Questionnaire and General Anxiety Disorder) PHQ-9 (Patient Health Questionnaire) PHQ-9 (Patient Health Questionnaire) Spanish Records Request Personal Use Records Request Personal Use Spanish Records Request Prior Doctor Records Request Prior Doctor Spanish Self Pay Waiver Self Pay Waiver Spanish Telehealth Agreement Update Demographics Returned Mail Vanderbilt - Parent Well Child Waiver Well Child Waiver Spanish

PHQ-9 and GAD (Patient Health Questionnaire and General Anxiety Disorder)

Patient Name *

First & Last

Date of Birth *

Today's Date *

Please indicate how often you have experienced the following over the last 2 weeks

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, or of hurting yourself *

If you answered yes to 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? *

If you answered no to all problems, select N/A

GAD-7

1) Feeling nervous, anxious or on the edge. *

2) Not being able to stop or control worrying. *

3) Worrying too much about different things.. *

4) Trouble Relaxing. *

5) Being so restless it's hard to sit still. *

6) Becoming easily annoyed or irritable. *

7) Feeling afraid as if something awful might happen. *

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If you answered yes to 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? *

* Required field