Priority Pediatrics PC

Patient Health/Teen Mood Questionnaire Form

Please register on my Updox Portal BEFORE starting this questionnaire, if you have not already previously registered, so that your work can be saved and completed. Once you are registered on the Portal, you will be able to retrieve past sent forms and resend if needed. Also do NOT use your BACK Button or REFRESH, or you will lose all your Form information and need to start over. When completed, click SEND and the form will come securely to me. Thank you. Dr. T

Your Name: * Date of Form Completion *

Instructions: How often have you been bothered by each of the following symptoms during the past two weeks? Please choose the best answer that indicates how you have been feeling. There are no right or wrong answers. When you click the "SEND" button, your form will come directly to Dr. T confidentially.

1. Have you been feeling down, depressed, irritable or hopeless? * 2. Have you little interest or pleasure in doing things? * 3. Have you had trouble falling asleep, staying asleep, or sleeping too much? * 4. Are you having a poor appetite, weight loss, or overeating? * 5. Have you been feeling tired, or having little energy? * 6. Have you been feeling badly about yourself _ or feeling that you are a failure, or that you have let yourself or your family down? * 7. Are you having trouble concentrating on things like school work, reading or watching TV? * 8. Do you feel that you are moving or speaking so slowly that other people could have noticed? Or the opposite _ being so fidgety or restless that you were moving around a lot more than usual? * 9. Have you had thoughts that you would be better off dead, or of hurting yourself in some way? * In the PAST YEAR, have you felt depressed or sad most days, even if you felt Okay sometimes? * If you are experiencing any of the problems on this form, 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? * Has there been a time in the PAST MONTH when you have had serious thoughts about hurting yourself? * Have you EVER in your WHOLE LIFE, tried to hurt yourself or end yourself? *

If you have ever had thoughts that you would be better off dead or of hurting yourself in some way, please call me and let's talk about it, or go to a hospital emergency room, or call 911.