PDF-patient-health-questionnaire.pdf

A471. Over the last 2 weeks how oft n have y ou been bot hered by any of t e fol wi ng probl em s a Little in terest o p easu e in d th in b Feel ng down depressed or hopel ss c Trouble fallingstaying as leep sleeping too m ch Feelin tired o h little en e Your answers will help in understanding problems that you may have Pl ease answer every question to the best of your ability A During the last 4 weeks how much have you been bothered by any of the following problems Not bothered 0 Bothered a little n n n n n n n n n n Minxes Inc. HEALTH QUESTIONNAIRE 1175 Long Lake Rd. # 100 Troy, MI 48098 Phone (2 48) 385 - 0085 Fax (248) - 247 - 1691 Has this condition existed in the past? Y敳 No Y (PHQ-9) Over the last 2 weeks , how often have you been bothered by any of the following problems? Feeling down, depressed, or hopeless 0 1 2 3 3. Feeling tired or having little energy 0 1 2 3 P Care Patients. UCLA Fielding School of Public Health. Hector P. Rodriguez. Beth Glenn. Roshan Bastani. Dylan Roby. Ritesh Mistry. National Cancer Institute. Russ Glasgow. Suzanne . Heurtin. -Roberts. 1. Take care of yourself, that is, eat, dress, bathe or use the toilet?Yes/No 2. Walk indoors, such as around your house?Yes/No 3. Walk a block or two on level ground?Yes/No 4. Climb a flight of stair CHIS 2019 ( Self - administered) Version 2. 7 1 February 27, 2020 Adult Respondents Age 18 and Older Collaborating Agencies:  UCLA Center for Health Policy Research  California Department of H PATIENT SLEEP/WAKE QUESTIONNAIRE Today’s Date: _________________ _________ Date of Birth: _______________ Sex: M F Ht: __________ Wt: ____________ Occupation: ________ none Does your iiCCAAHHEEOOuuttccoommeessCCaallccuullaattoorrCChhrroonniiccDDiisseeaasseessUUsseerrMMaannuuaallcommon chronic diseaseoutcome measures Updated August 2013Expected date of revision August 2015Prepared 18-25 BILLING ADDRESS EMAIL ADDRESSEMERGENCY CONTACTNAMEPHONE NUMBERRELATIONINSURANCE CARRIERBILLING ADDRESS IF DIFFERENT FROM ABOVESUBSCRIBERS NAME AND DOB HOW DID YOU HEAR ABOUT USFIRST AND LAST NA Patient Name: _________________________________________ Date: ___________________ Not at all Several days More than half the days Nearly every day 1. Over the last 2 weeks , how often have yo MRN: Patient Label) The following questions ask about your feelings There are no right or wrong answers. Please be sure None of 9. Made you feel anxious about the 10. Made you feel anxious about tr of Adolescent Depression. Charles E. Irwin, Jr., . MD. Distinguished Professor of . Pediatrics. Director, Division . of Adolescent & Young Adult Medicine. Department of Pediatrics. UCSF Benioff Children’s Hospital, San Francisco. Activity/Function . Outcome Measures. Dr Ann Taylor. Prof Ernest Choy. http://www.paincommunitycentre.org/. http://. twitter.com/paincommunity. Background. People living with long term conditions can experience physical activity limitations or suffer from increase symptoms during activity.