Oral Drug Screen
Required once on intake. Document if performed during this visit.
PHQ-9 Depression Screening
Over the last 2 weeks, how often have you been bothered by the following?
1.Little interest or pleasure in doing things
2.Feeling down, depressed, or hopeless
3.Trouble falling/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
7.Trouble concentrating on things
8.Moving or speaking so slowly that others noticed
9.Thoughts that you would be better off dead or hurting yourself
0
Minimal
0-4 Minimal · 5-9 Mild · 10-14 Moderate · 15-19 Mod-Severe · 20-27 Severe
GAD-7 Anxiety Screening
Over the last 2 weeks, how often have you been bothered by the following?
1.Feeling nervous, anxious, or on edge
2.Not being able to stop or control worrying
3.Worrying too much about different things
4.Trouble relaxing
5.Being so restless that it's hard to sit still
6.Becoming easily annoyed or irritable
7.Feeling afraid as if something awful might happen
0
Minimal
0-4 Minimal · 5-9 Mild · 10-14 Moderate · 15-21 Severe
SBIRT Screening
Screening, Brief Intervention, and Referral to Treatment
1.Do you drink alcohol?
2.Have you ever used recreational drugs?
3.Do you smoke or use tobacco?
4.Have you ever felt you should cut down on drinking or drug use?
5.Has substance use ever caused problems in your life?
0
No Risk
0 None · 1-2 Low · 3-4 Moderate · 5 High
Rapid Mood Screener (RMS)
Bipolar Disorder Screening
1.Have you experienced periods of feeling so happy or energetic that others thought something was wrong?
2.Have you had periods where you needed much less sleep than usual?
3.Have you had periods of racing thoughts or talking more than usual?
4.Have you experienced a period of reckless behavior?
5.Has a healthcare professional ever told you that you have bipolar disorder?
6.Has a blood relative been diagnosed with bipolar disorder?
0
Low Risk
0-2 Low · 3-4 Moderate · 5-6 High Risk
Vision & Hearing
1.Do you have any problems with your vision (blurred vision, difficulty reading, etc.)?
2.Do you wear glasses or contact lenses?
3.Do you have difficulty hearing or understanding conversations?
4.Do you use hearing aids?
Cognitive Assessment
Brief cognitive screening — rate the patient's current functioning:
1.Orientation (aware of person, place, time, situation)
2.Attention & Concentration
3.Memory (short-term recall)
4.Judgment & Insight
0
Intact
0 Intact · 1-4 Mild · 5-8 Moderate · 9-12 Severe
Falls & Mobility Risk Assessment
This section applies to patients aged 65 and older.
1.Have you fallen in the past 6 months?
2.Do you feel unsteady when standing or walking?
3.Do you use a cane, walker, or other assistive device?
4.Do you take 4 or more medications daily?
5.Do you have dizziness or lightheadedness when standing up?
0
Low Risk
0 Low · 1-2 Moderate · 3-5 High Risk