Yoga Class

Adult Questionnaires

Consent

  • Consent for Tele-Health Services

  • Influenza Vaccine Consent and Screening Form for Adults

  • Influenza Vaccine Consent and Screening Form for Adults (Revised without intranasal)

General Medical - Adult

  • Adult Primary Care Screening Tool

  • Adult Self-Report (ASR)*

  • DHCS 7098 H - Staying Healthy Assessment Adult (SHA Adult)

  • DHCS 7098 I - Staying Healthy Assessment Senior (SHA Senior)

  • Generalized Self-Efficacy Scale (GSES)

  • International Prostate Symptom Score (IPSS)

  • Medicare Annual Wellness Questionnaire

  • Resilience Builders Group Encounter

  • STEADI - Stopping Elderly Accidents Death & Injuries 
     

General Medical - Asthma

General Medical - Data Collection

  • Advocate Medical Group Intro 

  • Pre Appointment COVID Screener

General Medical - General

  • Family Cardiac History

  • Family Medical History

  • Family Questions

  • Sexuality and Gender Questionnaire

  • Visit Priorities

General Medical - JCAHO Specific

  • Communication Preferences (JCAHO) and Patient Safety Screen
     

General Medical - Past History

  • Family Cardiac History

  • Family Medical History

General Medical - Social Determinants of Health

General Medical - Special Health Care Needs

General Medical - Sports

  • Sport Concussion Assessment Tool - 3rd edition: Self-administered background and symptom evaluation for patients 13 years+

  •  Concussion Assessment Tool 2: Symptom EvaluationSport
     

Mental Health - Abnormal Movements

Mental Health - ADHD

  • Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

Mental Health - Anxiety

 

Mental Health - Borderline

Mental Health - Depression/Mood Disorders/Suicide

  • Ask Suicide Screening Questions (ASQ) 

  • Columbia-Suicide Severity Rating Scale

  • Launch Weekly Assessment Measure

  • Mood and Feelings Questionnaire: Adult Self-Report Long Version (MFQ: Adult Self-Report Long Version)

  • Mood and Feelings Questionnaire: Adult Self-Report Short Version (MFQ: Adult Self-Report Short Version)

  • Mood Disorder Questionnaire (MDQ)

  • Patient Health Questionnaire 4 (PHQ-4)

  • PHQ-9 for Adults

  • PRIME-MD PHQ-2 (PHQ-2)

  • The 7 Up 7 Down Inventory

 

Mental Health - Diagnostic

  • Diagnosis Reporting Tool

  • Weiss Symptom Record (WSR)

 

Mental Health - Eating Disorders

  • Eating Attitudes Test (EAT 26)

  • SCOFF

 

Mental Health - Family/Environment

Mental Health - General Adult

  • ABASI Self-injury Questionnaire

  • Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

  • Anxiety Screen for Adults

  • Anxiety Screen for Adults short version

  • Alcohol Use Disorders Identification Test—Consumption (AUDIT-C)

  • Balanced Measure of Psychological Needs Scale (BMPN)

  • CAGE-AID

  • DAST-10* Drug Abuse Screening Test

  • Emerging Adults Developmental Milestones Questionnaire

  • IDEA: Inventory of the Dimensions of Emerging Adulthood

  • KIMS - Kentucky Inventory of Mindfulness Skills

  • Mood and Feelings Questionnaire: Adult Self-Report Long Version (MFQ: Adult Self-Report Long Version)

  • Mood and Feelings Questionnaire: Adult Self-Report Short Version (MFQ: Adult Self-Report Short Version)

  • Older Adult Self-Report (OASR)*

  • Opioid Risk Tool – 2 (ORT 2)

  • Patient Health Questionnaire 4 (PHQ-4)

  • Patient Health Questionnaire 9 (PHQ-9 for Adults)

  • PRIME-MD PHQ-2

  • Problematic and Risky Internet Use Screening Scale 18 (PRIUSS-18)

  • UCLA Loneliness Scale Version 3

 

Mental Health - Obsessive-Compulsive 

Mental Health - Personality Disorder

Mental Health - Substance

  • Alcohol Use Disorders Identification Test—Consumption (AUDIT-C)

  • CAGE-AID

  • Cannabis Use Disorders Identification Test - Revised (CUDIT-R)

  • Drug Abuse Screening Test 10 and AUDIT (DAST-10 and AUDIT)* 

  • Drug Abuse Screening Test: 10 item version (DAST-10)*

  • GPRA Behavioral Health Form Client Facing

  • GPRA Behavioral Health Form Staff Facing

  • GPRA Office Form

 

* These questionnaires may have an additional cost associated with them. Ask your account manager or sales representative for details.