Attached question

(please circle your answer & check the boxes that apply to you ) Not at all Several days More than half the days Nearly Every day 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or having little energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed, or the opposite - being so fidgety or restless that you've been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead, or hurting yourself in some way 0 1 2 3 Total (10) add columns: 1. Feeling nervous, anxious or on edge 0 1 2 3 2. Not being able to stop or control worrying 0 1 2 3 3. Worrying too much about different things 0 1 2 3 4. Trouble relaxing 0 1 2 3 5. Being so restless that it is hard to sit still 0 1 2 3 6. Becoming easily annoyed or irritable 0 1 2 3 7. Feeling afraid as if something awful might happen 0 1 2 3 Total (8) *adapted from PhQ 9, GAD7, PC-PTSD and AUDIT 1/24/11 add columns: Provider:__________________________________ Please also complete back side No Yes No Yes No Yes No Yes No Yes (3) Please circle your answer 0 1 2 3 4 How often do you have one drink containing alcohol? Never Monthly or less 2-4 times a month 2-3 times a week 4+ times per week How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more How often do you have four or more drinks on one occasion? Never Less than monthly Monthly W eekly Daily or almost daily …found that you were not able to stop drinking once you had started? Never Less than monthly Monthly W eekly Daily or almost daily …failed to do what was normally expected from you because of drinking? Never Less than monthly Monthly W eekly Daily or almost daily …needed a first drink in the morning to get yourself going after heavy drinking? Never Less than monthly Monthly W eekly Daily or almost daily …had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly W eekly Daily or almost daily …been unable to remember what happened the night before because you had been drinking? Never Less than monthly Monthly W eekly Daily or almost daily 0 2 4 Have you or someone else been injured as a result of your drinking? No Yes, during the last year Has a relative, friend, doctor or other health worker been concerned about your drinking or suggested you cut down? No Yes, during the last year (8) Standard serving of one drink:

12 ounces of beer or wine cooler 1.5 ounces of 80 proof liquor 5 ounces of wine 4 ounces of brandy, liqueur or aperitif Are you currently in any physical pain?

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month , you: These questions are about your drinking habits. W e’ve listed the serving size of one drink below.

How often during the last year have you…… 4. Felt numb or detached from others, activities, or your surroundings?

3. Were constantly on guard, watchful, or easily startled?

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? Total: 1. Have had nightmares about it or thought about it when you did not want to?

Drinking alcohol can affect your health. This is especially important if you take certain medication s. W e want to help you stay healthy and lower your risk for the problems that can be caused by drinking. Yes, but not in the last year Yes, but not in the last year