Patient Health Questionnaire
1. Little interest or pleasure in doing things once found enjoyable?
2. Feeling down, depressed, or hopeless?
3. Trouble falling or staying asleep, or sleeping too much?
4. Feeling tired or having no energy?
5. Poor appetite or overeating?
6. Feeling bad about yourself?
7. Trouble concentrating on things?
8. Moving or speaking so slowly that others have noticed?
9. Thoughts that you'd be better off dead?
Generalized Anxiety Disorder
1. Have you been 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?
Adverse Childhood Experiences
1. Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you? OR act in a way that made you fearful that you would be hurt?
2. Did a parent or other adult in the household often push, grab, slap, or throw something at you? OR ever hurt you so bad that you had marks or were injured?
3. Did an adult or person at least 5 years or older than you ever touch or fondle you or have you touch their body in a sexual way? Or try to actually have sex with you?
4. Did you often feel that no one in your family loved you or thought you were important or special? OR your family didn't look out for each other, feel close to each other?
5. Did you often feel that you didn't have enough to eat, had no clean clothes, or no one to protect you? Or were your parents too drunk or high to take care of you?
6. Were your parents ever separated or divorced?
7. Was your caregiver ever pushed, grabbed, slapped, kicked or hit with a fist or another object or threatened with a weapon?
8. Did you live with anyone who was a problem drinker or alcoholic or used street drugs?
9. Was a household member depressed or mentally ill, or did a household member attempt suicide?
10. Did a household member go to prison?