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 all Some days More than half the days Nearly every day Feeling down, depressed or hopeless* Not at all Some days More than half the days Nearly every day What is your housing situation today?* I have housing I 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 question Are you worried about losing your housing?* Yes No I choose not to answer this question What is your current work situation?* Full-time work Part-time or temporary work Unemployed seeking work Otherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver) I choose not to answer this question In 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 medications Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need No Otherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver) I choose not to answer this question How 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 week 1 or 2 times a week 3 to 5 times a week 5 or more times a week I choose not to answer this question Stress is when someone feels tense, nervous, anxious, or can’t sleep at night because their mind is troubled. How stressed are you?* Not at all A little bit Somewhat Quite a bit Very much I choose not to answer this question In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?* Yes No I choose not to answer this question Are you a refugee?* Yes No I choose not to answer this question Do you feel physically and emotionally safe where you currently live?* Yes No Unsure I choose not to answer this question In the past year, have you been afraid of your partner or ex-partner?* Yes No Unsure I have not had a partner in the past year I choose not to answer this question CAGE-AID QuestionnaireAlcohol and Drug Use ScreenHave you ever felt you ought to cut down on your drinking or drug use?* Yes No Have people annoyed you by criticizing your drinking or drug use?* Yes No Have you ever felt bad or guilty about your drinking or drug use?* Yes No Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover?* Yes No Signature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
English
Spanish