Wellness Form

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.

Alcohol Screen


Do you sometimes drink alcoholic beverages?    

National Institute on Alcohol Abuse & Alcoholism (NIAAA) Screening

Tobacco Screen

STD Screen

Please proceed to reverse side to complete questionnaire

Depression Screen

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.

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?