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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
GAD-7
First Name
*
Last Name
*
Date of birth
*
Over the last two weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious, or on edge
Not at all
Several days
More than half the days
Nearly every day
Not being able to stop or control worrying
Not at all
Several days
More than half the days
Nearly every day
Worrying too much about different things
Not at all
Several days
More than half the days
Nearly every day
Trouble relaxing
Not at all
Several days
More than half the days
Nearly every day
Being so restless that it is hard to sit still
Not at all
Several days
More than half the days
Nearly every day
Becoming easily annoyed or irritable
Not at all
Several days
More than half the days
Nearly every day
Feeling afraid, as if something awful might happen
Not at all
Several days
More than half the days
Nearly every day
If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
* Required field
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