SCREENINGS

Screenings
Today's Date*
MM slash DD slash YYYY
Your Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Preferred Phone Number*
Preferred Phone is*
Secondary Phone Number*
COMPREHENSIVE ASSESSMENT OF PAIN AND COMORBIDITIES
Please answer all questions, please respond carefully to this question. Try to choose the choice that most accurately reflects your abilities.
What best describes your functional abilities?*
- Stay in bed all day Feel hopeless and helpless Non-functioning about life
- Stay in bed at least half the day Have no contact with outside world
- Get out of bed but don’t get dressed Stay at home all day
- Get dressed in the morning, minimal activities at home Contact with friends via phone, email
- Struggle but fulfill daily home responsibilities No outside activity Not able to work/volunteer
- Do simple chores around the house Minimal activities outside of home two days a week
- Work/volunteer limited hours Take part in limited social activities on weekends
- Work/volunteer for a few hours daily. Can be active at least five hours a day. Can make plans to do simple activities on weekends
- Work/volunteer for at least six hours daily Have energy to make plans for one evening social activity during the week Active on weekends
- Take part in family life Work/volunteer/be active eight hours daily Outside social activities limited
- Go to work/volunteer each day Normal daily activities each day Normal Quality of Life Have a social life outside of work Take an active part in family life
Little interest or pleasure in doing things*
- Not at all
- Less than half the days
- More than half the days
- Nearly everyday
Feeling down, depressed or helpless*
- Not at all
- Less than half the days
- More than half the days
- Nearly everyday
Trouble falling or staying asleep, or sleeping too much*
- Not at all
- Less than half the days
- More than half the days
- Nearly everyday
Feeling tired or having little energy*
- Not at all
- Less than half the days
- More than half the days
- Nearly everyday
Poor appetite or over eating*
- Not at all
- Less than half the days
- More than half the days
- Nearly everyday
Feeling bad about yourself or feeling like you are a failure*
- Not at all
- Less than half the days
- More than half the days
- Nearly everyday
Trouble concentrating on things such as reading or watching TV*
- Not at all
- Less than half the days
- More than half the days
- Nearly everyday
Moving or speaking either too slowly or being too fidgety*
- Not at all
- Less than half the days
- More than half the days
- Nearly everyday
Thoughts that you are better off being dead*
- Not at all
- Less than half the days
- More than half the days
- Nearly everyday
SUICIDE SCREENING
During the last month,
Have you wished you were dead or wished you could go to sleep and not wake up?*
- Yes
- No
Have you actually had any thoughts of killing yourself?*
- Yes
- No
Have you been thinking about how you might kill yourself?*
- Yes
- No
Have you had these thoughts and had some intention of acting on them?*
- Yes
- No
Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?*
- Yes
- No
Have you ever done anything, started to do anything, or prepared to do anything to end your life?*
- Yes
- No
PAIN INTENSITY- choose one choice- During the past week*
- I can tolerate the pain I have without having to use pain killers
- The pain is bad but I manage without taking pain killers
- Pain killers give complete relief from pain
- Pain killers give moderate relief from pain
- Pain killers give very little relief from pain
- Pain killers have no effect on the pain and I do not use them
PERSONAL CARE During the past week,*
- I can look after myself normally without causing extra pain
- I can look after myself normally but it causes extra pain
- It is painful to look after myself and I am slow and careful
- I need some help but manage most of my personal care
- I need help every day in most aspects of self care
- I do not get dressed wash with difficulty and stay in bed
LIFTING During the last week,*
- I can lift heavy weights without extra pain
- I can lift heavy weights but it gives extra pain
- Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned for example on a table
- Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned
- I can lift only very light weights
- I cannot lift or carry anything at all
WALKING During the last week*
- Pain does not prevent me walking any distance
- Pain prevents me walking more than 1 mile
- Pain prevents me walking more than 0.5 miles
- Pain prevents me walking more than 0.25 miles
- I can only walk using a stick or crutches
- I am in bed most of the time and have to crawl to the toilet
SITTING During the last week*
- I can sit in any chair as long as I like
- I can only sit in my favorite chair as long as I like
- Pain prevents me sitting more than 1 hour
- Pain prevents me sitting more than half an hour
- Pain prevents me from sitting more than 10 minutes
- Pain prevents me from sitting at all
STANDING During the last week*
- I can stand as long as I want without extra pain
- I can stand as long as I want but it gives me extra pain
- Pain prevents me from standing for more than 1 hour
- Pain prevents me from standing for more than 30 minutes
- Pain prevents me from standing for more than 10 minutes
- Pain prevents me from standing at all
SLEEPING During the last week*
- Pain does not prevent me from sleeping well
- I can sleep well only by using tablets
- Even when I take tablets I have less than 6 hours sleep
- Even when I take tablets I have less than 4 hours sleep
- Even when I take tablets I have less than 2 hours of sleep
- Pain prevents any sex life at all
SEX LIFE*
- My sex life is normal and causes no extra pain
- My sex life is normal but causes some extra pain
- My sex life is nearly normal but is very painful
- My sex life is severely restricted by pain
- My sex life is nearly absent because of pain
- Pain prevents any sex life at all
SOCIAL LIFE*
- My social life is normal and gives me no extra pain
- My social life is normal but increases the degree of pain
- Pain has no significant effect on my social life apart from limiting energetic interests such as dancing
- Pain has restricted my social life and I do not go out as often
- Pain has restricted my social life to my home
- I have no social life because of pain
TRAVELING*
- I can travel anywhere without extra pain
- I can travel anywhere but it gives me extra pain
- Pain is bad but I manage journeys over 2 hours
- Pain restricts me to journeys of less than 1 hour
- Pain restricts me to short necessary journeys under 30 minutes
- Pain prevents me from traveling except to the doctor or hospital
Do you smoke?*
Do you consume alcohol?*
If yes, how many alcoholic drinks do you consume in a week?
Do you use any illegal drugs?*
Have you ever abused or overused prescription drugs?*
Gender at birth*
- Male
- Female
Are you between the age of 16-45*
- Yes
- No
Do you have a family history of substance abuse?*
- Alcohol
- Illegal Drugs
- Prescription Drugs
- None
Do you have a family history of substance abuse?*
- Alcohol
- Illegal Drugs
- Prescription Drugs
- None
Do you have a personal history of substance abuse?*
- Alcohol
- Illegal Drugs
- Prescription Drugs
- None
Do you have a history of preadolescent sexual abuse?*
- Yes
- No
Do you have a history of preadolescent sexual abuse?*
- Yes
- No
Do you have a Psychological Disorder? If yes, please check all that apply.*
- ADD, OCD, Bipolar, Schizophrenia
- Depression
- None
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Screenings

COMPREHENSIVE ASSESSMENT OF PAIN AND COMORBIDITIES

SUICIDE SCREENING