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Osteopathic Family Medicine, LLC
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Alcohol Questionnaire
Change of contact or insurance information
Depression Screening Questionaire (PHQ-9)
Eating Disorder Screening
GAD-7
Medicare Health Risk Assessment
Patient Satisfaction Survey - CAHPS/PCMH Version 3.0
Social Determinants of Health
Alcohol Questionnaire
First Name
*
Last Name
*
Date of Birth
*
Do you ever drink alcohol
NO
YES
Have any of the following happened to you more than once in the last 6 months?
You drank alcohol even though a doctor suggested that you stop drinking because of a problem with your health.
NO
YES
You drank alcohol, were high from alcohol, or hung over while you were working, going to school, or taking care of children or other responsibilities.
NO
YES
You missed or were late for work, school, or other activities because you were drinking or hung over.
NO
YES
You had a problem getting along with other people while you were drinking.
NO
YES
You drove a car after having several drinks or after drinking too much.
NO
YES
* Required field
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