MHCAQ

* Patient Identification Number

PHQ-9
Over the last 2 weeks, how often have you been bothered by any of the following problems?

	Not at all	Several days	More than half the days	Nearly every day
* 1. Little interest or pleasure in doing things

* 2. Feeling down, depressed, or hopeless

* 3. Trouble falling or staying asleep, or sleeping too much

* 4. Feeling tired or having little energy

* 5. Poor appetite or overeating

* 6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down

* 7. Trouble concentrating on things, such as reading the newspaper or watching television

* 8. 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

* 9. Thoughts that you would be better off dead or of hurting yourself in some way

* If you checked off any problems, 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?

For all of the above problems, I selected "Not at all"

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

GAD-7
Over the last 2 weeks, how often have you been bothered by the following problems?

* MHCAQ
In the past 12 months, did you want or think you needed help for emotional or stress-related problems such as feeling sad, blue, anxious, or nervous?

No

Yes

* Are you currently receiving treatment, such as medication, therapy or counseling, for anxiety, depression, and/or emotional or stress-related problems?

No

Yes

* For which problem are you currently receiving treatment? Select all that apply.

Anxiety

Depression

Other emotional or stress-related problems

* Are you currently being treated or have you been treated in the last 12 months with medication for these problems?

No

Yes

From the list below, select all of the medications that you are currently taking or have taken over the last 12 months for depression, anxiety, and/or other emotional or stress-related problems.

* How helpful were/are these medications to you?

Not helpful at all

A little helpful

Somewhat helpful

Very helpful

* If you are not currently receiving medication for depression, anxiety, and/or other
emotional or stress-related problems, what are the reasons? Select all that apply

* Over the past 12 months, have you received therapy or counseling for depression, anxiety, and/or other emotional or stress-related problems?

No

Yes

* Are you currently receiving therapy or counseling for depression, anxiety, and/or other emotional or stress-related problems?

No

Yes

* How many therapy or counseling visits have you had over the last 12 months?

* How helpful was/is therapy or counseling to you?

Not helpful at all

A little helpful

Somewhat helpful

Very helpful

* If you are not currently receiving medication for depression, anxiety, and/or other
emotional or stress-related problems, what are the reasons? Select all that apply

* If you are not receiving therapy or counseling for depression, anxiety, and/or other emotional or stress-related problems, what are the reasons?