Southern Nevada Family & Occupational Health

Full Name * Date of Birth * Insurance Plan *

Well-Being Assessment

1. Do you have any problems with dizziness, balance, or walking? * 2. Do you have numbness, tingling, or burning in your hands or feet? * 3. Are you physically active? * If yes, how many times per week do you exercise? 4. Do you have a device for mobility? * If yes, select all that apply 5. Have you had any recent vision changes? * 6. Have you had any recent hearing changes? * 7. Have you had problems with urinary incontinence, the leakage of urine? * 8. Have you had any problems with your short-term memory? * What did you have for dinner last night? * 9. Have you had any problems with your long-term memory? * Where were you born? * 10. Are you being psychologically or physically abused at home? * 11. Do you have a Living Will or Advanced Directive? * 12. Please select the number that best describes your overall pain level. * 13. How would you rate your overall health? Please select one. * 14. Do you drink alcohol? * If yes, how many drinks per week? 15. Have you ever abused alcohol or any other substance in the past, or been referred to rehab? * If yes, what substance and when? 16. Have you fallen in the last 3 months? * If yes, how many times? If yes, have there been any new medications started around the time of the fall? If yes, were you using an assistive device? If yes, date the last fall occurred? If yes, please select the circumstances of the fall.

PHQ-9: Patient Health Questionnaire - Symptom Checklist

Over the past two (2) weeks, how often have you been bothered by any of the following problems? Please read each item carefully and select a response.

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 of dead, or of hurting yourself. * If you have 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?

Activities of Daily Living

Do you have any problems completing the following activities?

1. Bathing * 2. Getting dressed * 3. Getting to and from the toilet * 4. Shopping * 5. Preparing meals * 6. Feeding yourself * 7. Using the telephone * 8. Housekeeping/Cleaning * 9. Laundry * 10. Managing your medications * 11. Managing household finances *

COPD Screening

This five-question screener may help you identify if you are at risk for COPD (chronic obstructive pulmonary disease). To complete the screening, select one option that best describes your answer for each question below.

1. During the PAST 4 WEEKS, how much of the time did you feel short of breath? * 2. Do you ever cough up any "stuff," such as mucus or phlegm? * 3. Please select the answer that best describes you in the PAST 12 MONTHS. I do less than I used to because of my breathing problems. * 4. Have you smoked at least 100 cigarettes in your ENTIRE LIFE? * 5. How old are you? *

TAPS 1 Assessment

1. In the PAST 12 MONTHS, how often have you used any tobacco product (for example, cigarettes, e-cigarettes, cigars, pipes, or smokeless tobacco)? * 2. In the PAST 12 MONTHS, how often have you had 5 or more drinks containing alcohol in one day? One standard drink is about 1 small glass of wine (5 oz), 1 beer (12 oz), or 1 single shot of liquor. * 3. In the PAST 12 MONTHS, how often have you had 4 or more drinks containing alcohol in one day? One standard drink is about 1 small glass of wine (5 oz), 1 beer (12 oz), or 1 single shot of liquor. (Copy) * 4. In the PAST 12 MONTHS, how often have you used any drugs including marijuana, cocaine or crack, heroin, methamphetamine (crystal meth), hallucinogens, ecstasy/MDMA? * 5. In the PAST 12 MONTHS, how often have you used any prescription medications just for the feeling, more than prescribe or that were not prescribed for you? Prescription medications that may be used this way include: Opiate pain relievers (for example, OxyContin, vicodin, Percocet, Methadone). Medications for anxiety or sleeping (for example, Xanax, Ativan, Klonopin). Medications for ADHD (for example, Adderall or Ritalin) * Electronic Signature * Today's Date *