At Associates in Women's Health, we are focused on all aspects of your health and wellness. Partnering with our patients is key in providing personalized healthcare. As part of your annual exam, we are asking you to complete the following questionnaire. Our medical assistants will review the information with you and enter it into your medical record prior to your exam. As always, we encourage you to discuss any concerns you have with your physician or nurse practitioner.
Do you sometimes drink alcoholic beverages?
How many times in the past year have you had 4 or more drinks in a day?
1 or 2
3 or 4
5 or 6
7 to 9
10 or More
Less than monthly
Daily or almost daily
National Institute on Alcohol Abuse & Alcoholism (NIAAA) Screening
Do you currently use tobacco products?
If yes, please indicate amount
Have you used tobacco products in the past?
If yes, when did you stop?
Are you interested in information on Smoking Cessation?YesNo
Are you interested in testing for sexually transmitted diseases (STD)?YesNo
Please proceed to reverse side to complete questionnaire
1. Over the last 2 weeks, how often have you been bothered by any of the following problems?
a. Little interest or pleasure in doing things.
Not at all
More than half the days
Nearly every day
b. Feeling down, depressed, or hopeless.
c. Trouble falling asleep, sleeping too much.
d. Feeling tired or having little energy.
e. Poor appetite or overeating.
f. Feeling bad about yourself – or that you are a failure or have let yourself or your family down.
g. Trouble concentrating on things, such as reading the newspaper or watching television.
h. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual.
i. Thoughts that you would be better off dead or of hurting yourself in some way.
2. If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
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