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#2 NEW PATIENT- ADHD assessment
*Binge eating disorder assessment
*FOLLOW-UP FORM: Anxiety
*FOLLOW-UP FORM: Depression
MDQ follow-up
Medication renewal form
*FOLLOW-UP FORM: ADHD
Patient survey
*FOLLOW-UP FORM: Anxiety
CUXOS Anxiety Scale:
Name:
*
Date:
*
What medications do you need filled today?
Which pharmacy would you like to use?
During the past week, including today:
1. I felt nervous or anxious
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
2. I worried a lot that something bad might happen.
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
3. I worried too much about things
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
4. I was jumpy and easily startled by noises
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
5. I felt keyed up or on edge
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
6. I felt scared
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
7. I had muscle tension or muscle aches:
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
8. I felt jittery
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
9. I was short of breath
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
10. My heart was pounding or racing
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
11. I had cold, clammy hands
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
12. I had a dry mouth
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
13. I was dizzy or light-headed
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
14. I felt sick to my stomach (nauseated)
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
15. I had diarrhea
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
16. I had hot flashes or chills
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
17. I urinated frequently
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
18. I felt a lump in my throat:
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
19. I was sweating
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
20. I had tingling feelings in my fingers or feet
*
0 = not at all
1= rarely true
2= sometimes true
3 - often true
4- almost always true
Please complete the questions below UNLESS you have already completed them on a different follow-up form.
Have you experienced any positive changes at home, work or school since your last visit? Any challenges?
Are there any questions or concerns that you would like to address?
Thank you! Please press 'submit'.
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