DEPARTMENT OF MENTAL HEALTH Manuel J. Jimenez, Jr., MA, MFT

Alcohol and Drug Services Director of Mental Health

P.O. Box 2087 Merced, CA 95344

This form will allow us to gather additional information to better meet your overall health care needs.

Your doctor will review it with you during your appointment.

Patient Name:______Date: ______

Male Female Age: ______Phone Number:______

Example X / Never / Sometimes / Alot * / Always *
  1. Over the past two weeks, how often have you had trouble falling asleep, staying asleep or sleeping too much?
/ / / /
  1. Over the past two weeks, how often have you felt little interest or pleasure in doing things?
/ / / /
  1. Over the past two weeks, how often have you felt down, depressed or hopeless?
/ / / /
  1. Over the past two weeks, how often have you felt anxious, worried or on edge?
/ / / /
  1. Over the past month, how often have you been bothered by disturbing memories, thoughts or images of a stressful experience in the past?
/ / / /
  1. Over the past month, how often have you been bothered by feeling very upset when something reminded you of a stressful experience of the past?
/ / / /
  1. Over the past month, how often were you more angry than you wanted?
/ / / /
  1. Over the past month, how often were you in pain?
/ / / /
  1. Over the past year, have you ever used drugs or medications other than those required for medical reasons?
/ / / /
  1. Over the past year, have you had four or more drinks on any occasion?
/ / / /
  1. Over the past year, were you ever able to stop using drugs or alcohol when you wanted to?
/ / / /
  1. Over the past year, have you felt frightened by what your partner says or does?
/ / / /
  1. Over the past year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?
/ / / /
  1. Over the past three months, how many times have you gone to the hospital emergency room to care for yourself?
/ Total:______
  1. Over the past three months, how many nights have you spent in the hospital?
/ Total:______
  1. Over the past the past three months, how many times have you not been able to perform your normal activities because of illness, pain, or nerves?
/ Total:______

For Official Use Only:PCP Initial: ______Date: ______BH Referral ____ Referral Declined ____ Not Needed

Comments:

Please Return this form to Mental Health/AOD staff

This is NOT a part of the client’s medical record