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- Bridgeville Office
- Washington Office
(412) 838-7311

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MED QUESTIONAIRE

Patient First Name

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Patient Last Name

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Email

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Date

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In general, how are you feeling?

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Please Explain

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Select the Rating

Have you been feeling Depressed?

Have you been feeling Depressed?

Depressed?

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Rating Scale:

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Frequency:

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Check the symptoms you currently hover:

Sad most of the time

Less interest in activities/hobbies

Decreased appetite

Sleeping More

Sleeping Less

Fatigue/Tiredness

Lack of Energy

Hopelessness

Worthlessness

Feelings of Guilt

Feelings of Guilt

Thinking about Death

Suicidal Thoughts

Manic?

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Rating Scale:

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Frequency:

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Have you been feeling Manic?

Have you been feeling Manic?

Manic?

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Rating Scale:

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Frequency:

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Check the symptoms you currently hover:

Inflated Self Esteem

Decreased need for sleep

More Talkative

Racing Thoughts

Distracted

Increase in Activity

Increase in reckless/risky behaviour

Apending too much $$

Have you been feeling Psychotic?

Have you been feeling Psychotic?

Psychotic?

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Rating Scale:

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Frequency:

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Check the symptoms you currently hover:

Difficult Thinking / Understanding

Disorientation

Racing Thoughts

Paranoia

Thought Disorder

Unwanted Thoughts

Unwanted Thoughts

Hearing Voices

Delusions

Unusual Behaviour

Inappropriate Behaviours

Visual Haluucinations

Incoherent Speech

Rapid Speech

Disorganised Speech

No Emotion

Have you been feeling Anxious?

Have you been feeling Anxious?

Anxious?

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Rating Scale:

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Frequency:

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Check the symptoms you currently hover:

Excessive Worry

Restlessness

Restlessness

Blank Mind/Difficulty Concentrating

Irritability

Muscle Tension

Difficulty Sleeping

Have you been feeling Social Anxiety?

Have you been feeling Social Anxiety?

Social Anxiety?

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Rating Scale:

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Frequency:

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Check the symptoms you currently hover:

Fear of Social Situations

Fear of enbarrasment

Fear of humiliation

Social Situation cause anxiety/panic

Avoids Social situations

Have you been feeling Panic Attacks?

Have you been feeling Panic Attacks?

Panic Attacks?

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Rating Scale:

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Frequency:

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Check the symptoms you currently hover:

Palpitaions/heart racing

Sweating

Trembling/shaking

Nausea/Vomiting

Shortness of Breaths

Feeling of Choking

Chest Pain/discomfort

Hot/Cold Flashes

Dizziness

Fear of losing control

Fear of dying

Have you been feeling Traumatic Stress?

Have you been feeling Traumatic Stress?

Traumatic Stress?

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Rating Scale:

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Frequency:

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Check the symptoms you currently hover:

Ongoing Recollections

Distressing Dreams

Acting/feeling event again

Distress to seeing resemblances

Attempts to avoid reminders of event

Attempts to avoid thoughts

Attempts to avoid reminders

Neg. beliefs of self/other/world

Difficluty feeling happy

Reckless Behavior

Less Interest

Feeling detached

Startled Responses

Hypervigilant

Irritability/Anger

Have you been feeling Focusing Issues?

Have you been feeling Focusing Issues?

Focusing Issues?

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Rating Scale:

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Frequency:

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Check the symptoms you currently hover:

Lack of attention to detail

Doesn't listen when spoken to

Not finishing tasks

Disorganised

Avoids tedious tasks

Loses things

Easily Distracted

Forgetful

Fidgets/Squirms

Unable to play quitely

Often "On the go"

Talks Excessively

Blurts out Answers

Difficluty waiting turn

Interrupts Others

Have you been feeling Behaviour Issues?

Have you been feeling Behaviour Issues?

Behaviour Issues?

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Rating Scale:

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Frequency:

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Check the symptoms you currently hover:

Loses Tember

Argues w/ Adults

Defiant

Annoys Others

Blames Others

Easily Distracted

Forgetful

Fidgets/Squirns

Unable to play quietly

Often "On the go"

Talks Excessively

Blurts out answers

Difficluty Waithing Turn

Interrupts Others

Have you been feeling Aggressive?

Have you been feeling Aggressive?

Aggressive?

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Rating Scale:

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Frequency:

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Check the symptoms you currently hover:

Severe Temper

Temper Outbrusts

Frequently Irritated

Verbal Aggression

Physical Aggression

Property Destruction

Hitting

Kicking

Biting

Throwing Objects

Explosive Anger

Easily Triggered

Frequently Angry

Taking Medication Regulary?

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Medication Side Effects:

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Sleep

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Recent Stressors:

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Other:

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Thoughts of harming self?

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If YES, since last visit?

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Thoughts of harming Others?

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If YES, since last visit?

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PATIENT RESOURCES

1370 Washington Pike Suite LL8
Bridgeville PA 15017

90 West Chestnut Suite 210
Washington PA 15301

Appointments (412) 838-7311

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