Patient Name* First Last Email* Patient Information ScreenersThis section to be completed by patient 12 years and older In the past 2 weeks, how often have you been bothered by any of the following:Little interest or pleasure in doing things*Not at allSome daysMore than half the daysNearly every dayFeeling down, depressed or hopeless*Not at allSome daysMore than half the daysNearly every dayWhat is your housing situation today?*I have housingI do not have housing (staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, or in a park)I choose not to answer this questionAre you worried about losing your housing?*YesNoI choose not to answer this questionWhat is your current work situation?*Full-time workPart-time or temporary workUnemployed seeking workOtherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)I choose not to answer this questionIn the past year, have you or any family members you live with been unable to get any of the following when it was really needed?*(check all that apply) Food Clothing Utilities Child Care Phone Medicine or Any Health Care (Medical, Dental, Mental Health, Vision) I choose not to answer this question Other services or things you've been unable to get?Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?*Yes, it has kept me from medical appointments or from getting my medicationsYes, it has kept me from non-medical meetings, appointments, work, or from getting things that I needNoOtherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)I choose not to answer this questionHow often do you see or talk to people that that you care about and feel close to? (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)*Less than once a week1 or 2 times a week3 to 5 times a week5 or more times a weekI choose not to answer this questionStress is when someone feels tense, nervous, anxious, or can’t sleep at night because their mind is troubled. How stressed are you?*Not at allA little bitSomewhatQuite a bitVery muchI choose not to answer this questionIn the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?*YesNoI choose not to answer this questionAre you a refugee?*YesNoI choose not to answer this questionDo you feel physically and emotionally safe where you currently live?*YesNoUnsureI choose not to answer this questionIn the past year, have you been afraid of your partner or ex-partner?*YesNoUnsureI have not had a partner in the past yearI choose not to answer this questionCAGE-AID QuestionnaireAlcohol and Drug Use ScreenHave you ever felt you ought to cut down on your drinking or drug use?*YesNoHave people annoyed you by criticizing your drinking or drug use?*YesNoHave you ever felt bad or guilty about your drinking or drug use?*YesNoHave you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover?*YesNoSignature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
