OLD-C. Initial Assessments GAD7, PHQ9, SCOFF

Initial Assessments

anxiety, depression, complex trauma, eating disorder risk, and substance abuse
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date of birth
GAD-7: Measures symptoms of anxiety

Over the last two weeks, how often have you been bothered by the following problems?*

	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 allSomewhat difficultVery difficultExtremely 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?*

	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 allSomewhat difficultVery difficultExtremely 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.*

	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?

Initial Assessments