Initial Assessments
anxiety, depression, complex trauma, eating disorder risk, and substance abuse
Name
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First Name
Last Name
Date of Birth
*
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Month
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Day
Year
Date of birth
GAD-7:
Measures symptoms of anxiety
Over the last two weeks, how often have you been bothered by the following problems?
*
Rows
Not sure at all (0) points each
Several days (1) point each
Over half the days (2) points each
Nearly every day (3) points each
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
7. Feeling afraid as if something awful might happen
GAD-7, total score
If you checked off any problems in the above table, how difficult have these 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
PHQ-9: Identifies depression and recent/current mood state
Over the last two weeks, how often have you been bothered by the following problems?
*
Rows
Not sure at all (0) points each
Several days (1) point each
Over half the days (2) points each
Nearly every day (3) points each
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 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 off dead or of hurting yourself in some way
PHQ-9, total score
If you checked off any problems in the above table, how difficult have these 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
SCOFF Questionnaire
This is a screening tool that can be used to identify who may be at risk or have an eating disorder. Please answer all questions.
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Rows
NO (0) points each
YES (1) point each
S. Do you make yourself Sick because you feel uncomfortably full?
C. Do you worry you have lost Control over how much you eat?
O. Have you recently lost more than One stone (14lbs) in a three-month period?
F. Do you believe yourself to be Fat when others say you are too thin?
F. Would you say that Food dominates your life?
SCOFF, total score
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