Village Family Clinic & Wellness Center

Available Forms

#1 NEW PATIENT - Mood disorder #2 NEW PATIENT- ADHD assessment #3 NEW PATIENT Health History form #4 NEW PATIENT - PHQ-9 #5 NEW PATIENT Epworth Sleepiness Scale #5 NEW PATIENT Epworth Sleepiness Scale #6 NEW PATIENT CUXOS Anxiety Scale *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'.

* Required field