FREE AND QUICK ONLINE CONFIDENTIAL SELF-SCREENING

This online Mental Health assessment takes approximately five minutes and will provide general feedback when completed. Please note that this assessment is not a formal diagnostic tool and should not be interpreted as such. This assessment is free and can be taken anonymously, if you choose.

MOOD DISORDER SELF-SCREENING TOOL

Welcome to your Mood Disorder Questionnaire

Name

Phone

Instructions: Please answer each question to the best of your ability.

QUESTION 1. Has there ever been a period of time when you were not your usual self and...

...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?

Yes

None

...you were so irritable that you shouted at people or started fights or arguments?

Yes

None

...you felt much more self-confident than usual?

Yes

None

...you got much less sleep than usual and found you didn't really miss it?

Yes

None

...you were much more talkative or spoke much faster than usual?

Yes

None

...thoughts raced through your head or you couldn't slow your mind down?

Yes

None

...you were so easily distracted by things around you that you had trouble concentrating or staying on track?

Yes

None

...you had much more energy than usual?

Yes

None

...you were much more active or did many more things than usual?

Yes

None

...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?

Yes

None

...you were much more interested in sex than usual?

Yes

None

...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?

Yes

None

...spending money got you or your family into trouble?

Yes

None

2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?

Yes

None

3. How much of a problem did any of these cause you – like being unable to work; having family, money or legal troubles; getting into arguments or fights?

No Problem

Minor Problem

Moderate Problem

Serious Problem

None

4. Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?

Yes

None

5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?

Yes

None

Time's up

Alcohol-AUDIT-Screening-tool

Welcome to your AUDIT Alcohol Screening Tool

Name

Phone

The AUDIT (Alcohol Use Disorders Identification Test) is an effective and reliable screening tool for detecting risky and harmful drinking patterns.
INSTRUCTIONS: by completing the following questions in the AUDIT Alcohol Screen you will be able to assess whether your
drinking is putting you at risk of alcohol-related harm:

Answer the following questions about your alcohol use during the past 12 months.
‘Select’ one box that best describes your answer to each question. Answer as accurately as you can.
When you have completed the questions SCORE them and put your total score in the box.

Thank you.

1. How often do you have a drink containing alcohol?

Never

Monthly or less

2-4 times a month

2-3 times a week

times a week

None

2. 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

None

3. How often do you have six or more standard drinks on one occasion?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

None

4. How often during the last year have you found that you were not able to stop drinking once you had started?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

None

5. How often during the last year have you failed to do what was normally expected of you because of drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

None

6. How often during the last year have you needed a drink first thing in the morning to get yourself going after a heavy drinking session?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

None

7. How often during the last year have you had a feeling of guilt or remorse after drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

None

8. How often during the last year have you been unable to remember what happened the night before because of your drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

None

9. Have you or someone else been injured because of your drinking?

Yes, but not in the last year

Yes, during the last year

None

10. Has a relative, friend, doctor or other healthcare worker been concerned about your drinking or suggested you cut down?

Yes, but not in the last year

Yes, during the last year

None

Time's up

BAI test (Beck Anxiety Inventory)

Welcome to your Beck Anxiety Inventory (BAI) Test

Name

Phone

Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by circling the number in the corresponding space in the column next to each symptom.

Numbness or tingling

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Feeling hot

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Wobbliness in legs

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Unable to relax

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Fear of worst happening

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Dizzy or lightheaded

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Heart pounding / racing

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Unsteady

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Terrified or afraid

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Nervous

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Feeling of choking

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Hands trembling

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Shaky / unsteady

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Fear of losing control

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Difficulty in breathing

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Fear of dying

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Scared

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Indigestion

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Faint / lightheaded

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Face flushed

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Hot / cold sweats

Not at all

Mildly, but it didn’t bother me much

Moderately – it wasn’t pleasant at times

Severely – it bothered me a lot

None

Time's up

Burnout Self-Test

Welcome to your Burnout Self-Test

Name

Phone

Instructions: For each question, place the corresponding number in the column that most applies.

I feel run down and drained of physical or emotional energy

Not At All

Rarely

Sometimes

Often

Very Often

None

I have negative thoughts about my job

Not At All

Rarely

Sometimes

Often

Very Often

None

I am harder and less sympathetic with people than perhaps they deserve

Not At All

Rarely

Sometimes

Often

Very Often

None

I am easily irritated by small problems, or by my co-workers

Not At All

Rarely

Sometimes

Often

Very Often

None

I feel misunderstood or unappreciated by my co-workers

Not At All

Rarely

Sometimes

Often

Very Often

None

I feel that I have no one to talk to

Not At All

Rarely

Sometimes

Often

Very Often

None

I feel that I am achieving less than I should

Not At All

Rarely

Sometimes

Often

Very Often

None

I feel under an unpleasant level of pressure to succeed

Not At All

Rarely

Sometimes

Often

Very Often

None

I feel that I am not getting what I want out of my job

Not At All

Rarely

Sometimes

Often

Very Often

None

I feel that I am in the wrong organization or profession

Not At All

Rarely

Sometimes

Often

Very Often

None

I am frustrated with parts of my job

Not At All

Rarely

Sometimes

Often

Very Often

None

I feel that organizational politics or bureaucracy frustrate my ability to do a good job

Not At All

Rarely

Sometimes

Often

Very Often

None

I feel that there is more work to do than I practically have the ability to do

Not At All

Rarely

Sometimes

Often

Very Often

None

I feel that I do not have time to do many of the things that are important to doing a good quality job

Not At All

Rarely

Sometimes

Often

Very Often

None

I find that I do not have time to plan as much as I want to

Not At All

Rarely

Sometimes

Often

Very Often

None

Time's up

Fagerstrom test

Welcome to your Fagerstrom Test for Nicotine Dependence

Name

Phone

Instruction: Please select one for each of the questions.

How soon after waking do you smoke your first cigarette?

Within 5 minutes

5-30 minutes

31-60 minutes

None

Do you find it difficult to refrain from smoking in places where it is forbidden? e.g Church, Library, etc.

Yes

None

Which cigarette would you hate to give up?

The first in the morning

Any other

None

How many cigarettes a day do you smoke?

10 or less

11-20

21-30

31 or more

None

Do you smoke more frequently in the morning?

Yes

None

Do you smoke even if you are sick in bed most of the day?

Yes

None

Time's up

ACE test for children

Welcome to your Adverse Childhood Experience (ACE) Questionnaire

Date

Name

Phone

This Questionnaire will ask you some questions about events that happened during your childhood; specifically the first 18 years of your life. The information you provide by answering these questions will allow us to better understand problems that may have occurred early in your life and allow us to explore how those problems may be impacting the challenges you are experiencing today.

This can be very helpful in the success of your treatment.
While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household often:

Swear at you, insult you, put you down, or humiliate you?
Or
Act in a way that made you afraid that you might be physically hurt?

Yes

None

2. Did a parent or other adult in the household often:

Push, grab, slap, or throw something at you?
Or
Ever hit you so hard that you had marks or were injured?

Yes

None

3. Did an adult or person at least 5 years older than you ever:

Touch or fondle you or have you touch their body in a sexual way?
Or
Attempt or actually have oral, anal, or vaginal intercourse with you?

Yes

None

4. Did you often feel that:

No one in your family loved you or thought you were important or special?
Or
Your family didn’t look out for each other, feel close to each other, or support each other?

Yes

None

5. Did you often feel that:

You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?
Or
Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

Yes

None

6. Were your parents ever separated or divorced?

Yes

None

7. Were any of your parents or other adult caregivers:

Often pushed, grabbed, slapped, or had something thrown at them?
Or
Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?
Or
Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

Yes

None

8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?

Yes

None

9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

Yes

None

10. Did a household member go to prison?

Yes

None

Time's up

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

Welcome to your Patient Health Questionnaire (PHQ-9)

Name

Phone

ID Number

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

1. Little interest or pleasure in doing things

Not at all

Several days

More than half the days

Nearly every day

None

2. Feeling down, depressed, or hopeless

Not at all

Several days

More than half the days

Nearly every day

None

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

Not at all

Several days

More than half the days

Nearly every day

None

4. Feeling tired or having little energy

Not at all

Several days

More than half the days

Nearly every day

None

5. Poor appetite or overeating

Not at all

Several days

More than half the days

Nearly every day

None

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

Not at all

Several days

More than half the days

Nearly every day

None

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

Not at all

Several days

More than half the days

Nearly every day

None

8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual

Not at all

Several days

More than half the days

Nearly every day

None

9. Thoughts that you would be better off dead, or of hurting yourself

Not at all

Several days

More than half the days

Nearly every day

None

10. If you checked off any problems, how difficult Not difficult at all have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

None

Time's up

Child and Adolescent Trauma Screen (CATS)-Youth Report

Welcome to your Child and Adolescent Trauma Screen (CATS)-Youth Report(7-17 years) Screening

Name of the child

Date

Completed by

Telephone

Stressful or scary events happen to many people. Below is a list of stressful and scary events that sometimes happen. Mark YES if it happened to you. Mark No if it didn’t happen to you.

1. Serious natural disaster like a flood, tornado, hurricane, earthquake, or fire.

Yes

None

2. Serious accident or injury like a car/bike crash, dog bite, or sports injury.

Yes

None

3. Threatened, hit or hurt badly within the family.

Yes

None

4. Threatened, hit or hurt badly in school or the community.

Yes

None

5. Attacked, stabbed, shot at or robbed by threat.

Yes

None

6. Seeing someone in the family threatened, hit or hurt badly.

Yes

None

7. Seeing someone in school or the community threatened, hit or hurt badly.

Yes

None

8. Someone doing sexual things to you or making you do sexual things to them when you couldn’t say no. Or when you were forced or pressured.

Yes

None

9. On line or in social media, someone asking or pressuring you to do something sexual. Like take or send pictures.

Yes

None

10. Someone bullying you in person. Saying very mean things that scare you.

Yes

None

11. Someone bullying you online. Saying very mean things that scare you.

Yes

None

12. Someone close to you dying suddenly or violently.

Yes

None

13. Stressful or scary medical procedure.

Yes

None

14. Being around war.

Yes

None

15. Other stressful or scary event? Select and bescribe below:

Yes

None

Comment

The following section has Questions about all the scary or stressful events that happened to you.
Mark 0, 1, 2 or 3 for how often the following things have bothered you in the last two weeks:
Never=0 / Once in a while=1 / Half the time=2 / Almost always=3

1. Upsetting thoughts or pictures about what happened that pop into your head.

Never

Once in a while

Half the time

Almost Always

None

2. Bad dreams reminding you of what happened.

Never

Once in a while

Half the time

Almost Always

None

3. Feeling as if what happened is happening all over again.

Never

Once in a while

Half the time

Almost Always

None

4. Feeling very upset when you are reminded of what happened.

Never

Once in a while

Half the time

Almost Always

None

5. Strong feelings in your body when you are reminded of what happened (sweating, heart beating fast, upset stomach).

Never

Once in a while

Half the time

Almost Always

None

6. Trying not to think about or talk about what happened. Or to not have feelings about it.

Never

Once in a while

Half the time

Almost Always

None

7. Staying away from people, places, things, or situations that remind you of what happened.

Never

Once in a while

Half the time

Almost Always

None

8. Not being able to remember part of what happened.

Never

Once in a while

Half the time

Almost Always

None

9. Negative thoughts about yourself or others. Thoughts like I won’t have a good life, no one can be trusted, the whole world is unsafe.

Never

Once in a while

Half the time

Almost Always

None

10. Blaming yourself for what happened, or blaming someone else when it isn’t their fault.

Never

Once in a while

Half the time

Almost Always

None

11. Bad feelings (afraid, angry, guilty, ashamed) a lot of the time.

Never

Once in a while

Half the time

Almost Always

None

12. Not wanting to do things you used to do.

Never

Once in a while

Half the time

Almost Always

None

13. Not feeling close to people.

Never

Once in a while

Half the time

Almost Always

None

14. Not being able to have good or happy feelings.

Never

Once in a while

Half the time

Almost Always

None

15. Feeling mad. Having fits of anger and taking it out on others.

Never

Once in a while

Half the time

Almost Always

None

16. Doing unsafe things.

Never

Once in a while

Half the time

Almost Always

None

17. Being overly careful or on guard (checking to see who is around you).

Never

Once in a while

Half the time

Almost Always

None

18. Being jumpy.

Never

Once in a while

Half the time

Almost Always

None

19. Problems paying attention.

Never

Once in a while

Half the time

Almost Always

None

20. Trouble falling or staying asleep.

Never

Once in a while

Half the time

Almost Always

None

For the following set of questions,
Please mark “YES” or “NO” if the problems you marked interfered with:

1. Getting along with others

Yes

None

2. Hobbies/Fun

Yes

None

3. School or work

Yes

None

4. Family relationships

Yes

None

5. General happiness

Yes

None

Time's up

ADHD DSM-5 Checklist

Welcome to your ADHD DSM-5 Checklist Screening

Name of child

Gender

Age

Date

Completed by:

Phone#

For each item below, select the answer that best describes this child.
0=Not at all; 1=Just a Little; 2=Often; 3= Very Often

Inattention Symptoms

1. fails to give attention to details or makes careless mistakes in schoolwork, work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

Not at all

Just a Little

Often

Very Often

None

2. has difficulty sustaining attention to tasks or play activities (e.g., has difficulty remaining focused during lectures; conversations; or lengthy reading).

Not at all

Just a little

Often

Very often

None

3. does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

Not at all

Just a little

Often

Very often

None

4. does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked.

Not at all

Just a little

Often

Very often

None

5. has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized with work; has poor time management; fails to meet deadlines).

Not at all

Just a little

Often

Very often

None

6. avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).

Not at all

Just a little

Often

Very often

None

7. loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

Not at all

Just a little

Often

Very often

None

8. Is easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

Not at all

Just a little

Often

Very often

None

9. is forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

Not at all

Just a little

Often

Very often

None

Hyperactive Symptoms

10. fidgets with or taps hands or feet or squirms in seat

Not at all

Just a little

Often

Very often

None

11. leaves seat in situations in which it is inappropriate (NOTE: in adolescents or adults may be limited to feelings of restlessness).

Not at all

Just a little

Often

Very often

None

12. unable to play or engage in leisure activities quietly

Not at all

Just a little

Often

Very often

None

13. has difficulty playing or engaging in leisure activities quietly

Not at all

Just a little

Often

Very often

None

14. is “on the go” or acts as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with)

Not at all

Just a little

Often

Very often

None

15. talks excessively

Not at all

Just a little

Often

Very often

None

Impulsive Symptoms

16. blurts out an answer before question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).

Not at all

Just a little

Often

Very often

None

17. has difficulty waiting his or her turn (e.g., while waiting in line).

Not at all

Just a little

Often

Very often

None

18. interrupts or intrudes on others (eg, butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults may intrude into or take over what others are doing)

Not at all

Just a little

Often

Very often

None

Approximately when did you first notice the behaviors that occur often or very often?

Do these symptoms impair the person’s functioning in two or more settings?

Yes

None

Where is there impairment? (select all that apply)

Home

School

Socially

Time's up

WHO-ASSIST_V3.0

Welcome to your WHO-ASSIST_V3.0

Name

Phone

INTERVIEWER ID

INTERVIEWEE ID

COUNTRY

CLINIC

Date

NOTE: BEFORE ASKING QUESTIONS, GIVE ASSIST RESPONSE CARD TO PATIENT

Question 1

(if completing follow-up please cross-check the patient’s answers with the answers given for Q1 at baseline. Any differences on this question should be queried)

In your life, which of the following substances have you ever used? (NON-MEDICAL USE ONLY)

1a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)

Tobacco products (cigarettes, chewing tobacco, cigars, etc.)

Yes

None

1b. Alcoholic beverages (beer, wine, spirits, etc.)

Alcoholic beverages (beer, wine, spirits, etc.)

Yes

None

1c. Cannabis (marijuana, pot, grass, hash, etc.)

Cannabis (marijuana, pot, grass, hash, etc.)

Yes

None

1d. Cocaine (coke, crack, etc.)

Cocaine (coke, crack, etc.)

Yes

None

1e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)

Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)

Yes

None

1f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)

Inhalants (nitrous, glue, petrol, paint thinner, etc.)

Yes

None

1g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)

Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)

Yes

None

1h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)

Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)

Yes

None

1i. Opioids (heroin, morphine, methadone, codeine, etc.)

Opioids (heroin, morphine, methadone, codeine, etc.)

Yes

None

1j. Other - specify:

Others - specify:

Yes

None

Comment

Probe if all answers are negative:
“Not even when you were in school?”

If "No" to all items, stop interview.
If "Yes" to any of these items, ask Question 2 for
each substance ever used.

Question 2

In the past three months, how often have you used the substances you mentioned (FIRST DRUG, SECOND DRUG, ETC)?

2a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)

Tobacco products (cigarettes, chewing tobacco, cigars, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

2b. Alcoholic beverages (beer, wine, spirits, etc.)

Alcoholic beverages (beer, wine, spirits, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

2c. Cannabis (marijuana, pot, grass, hash, etc.)

Cannabis (marijuana, pot, grass, hash, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

2d. Cocaine (coke, crack, etc.)

Cocaine (coke, crack, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

2e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)

Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

2f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)

Inhalants (nitrous, glue, petrol, paint thinner, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

Comment

2g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)

Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

2h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)

Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

2i. Opioids (heroin, morphine, methadone, codeine, etc.)

Opioids (heroin, morphine, methadone, codeine, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

2j. Other - specify:

Other - specify:

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

Comment

If "Never" to all items in Question 2, skip to Question 6.
If any substances in Question 2 were used in the previous three months, continue with Questions 3, 4 & 5 for each substance used.

Question 3

During the past three months, how often have you had a strong desire or urge to use (FIRST DRUG, SECOND DRUG, ETC)?

3a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)

(cigarettes, chewing tobacco, cigars, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

3b. Alcoholic beverages (beer, wine, spirits, etc.)

(beer, wine, spirits, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

3c. Cannabis (marijuana, pot, grass, hash, etc.)

(marijuana, pot, grass, hash, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

3d. Cocaine (coke, crack, etc.)

(coke, crack, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

3e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)

Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

3f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)

(nitrous, glue, petrol, paint thinner, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

3g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)

(Valium, Serepax, Rohypnol, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

3h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)

(LSD, acid, mushrooms, PCP, Special K, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

3i. Opioids (heroin, morphine, methadone, codeine, etc.)

(heroin, morphine, methadone, codeine, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

3j. Other - specify:

Others - specify:

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

Comment

Question 4

During the past three months, how often has your use of (FIRST DRUG, SECOND DRUG, ETC) led to health, social, legal or financial problems?

4a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)

(cigarettes, chewing tobacco, cigars, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

4b. Alcoholic beverages (beer, wine, spirits, etc.)

(beer, wine, spirits, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

4c. Cannabis (marijuana, pot, grass, hash, etc.)

(marijuana, pot, grass, hash, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

4d. Cocaine (coke, crack, etc.)

(coke, crack, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

4e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

4f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

4g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

4h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

4i. Opioids (heroin, morphine, methadone, codeine, etc.)

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

4.j. Other - specify:

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

Comment

Question 5

During the past three months, how often have you failed to do what was normally expected of you because of your use of (FIRST DRUG, SECOND DRUG, ETC)?

Hint

5a. Tobacco products

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

5b. Alcoholic beverages (beer, wine, spirits, etc.)

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

5c. Cannabis (marijuana, pot, grass, hash, etc.)

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

d. Cocaine (coke, crack, etc.)

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

5e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

5f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

5g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

5h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

5i. Opioids (heroin, morphine, methadone, codeine, etc.)

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

5j. Other - specify:

(speed, diet pills, ecstasy, etc.)

Never

Once or Twice

Monthly

Weekly

Daily or almost Daily

None

Ask Questions 6 & 7 for all substances ever used (i.e. those endorsed in Question 1)

Hint

Question 6

Has a friend or relative or anyone else ever expressed concern about your use of
(FIRST DRUG, SECOND DRUG, ETC.)?

Hint

6a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

6b. Alcoholic beverages (beer, wine, spirits, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

6c. Cannabis (marijuana, pot, grass, hash, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

6d. Cocaine (coke, crack, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

6e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

6f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

6g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

6h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

6i. Opioids (heroin, morphine, methadone, codeine, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

6j. Other – specify:

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

Comment

Question 7

Have you ever tried and failed to control, cut down or stop using (FIRST DRUG, SECOND DRUG, ETC.)?

Hint

7a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

7b. Alcoholic beverages (beer, wine, spirits, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

7c. Cannabis (marijuana, pot, grass, hash, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

7d. Cocaine (coke, crack, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

7e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

7f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

7g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

7h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

7i. Opioids (heroin, morphine, methadone, codeine, etc.)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

7j. Other – specify:

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

Comment

Question 8

Hint

Have you ever used any drug by injection? (NON-MEDICAL USE ONLY)

(speed, diet pills, ecstasy, etc.)

No, Never

Yes, in the past 3 months

Yes, but not in the past 3 months

None

IMPORTANT NOTE:
Patients who have injected drugs in the last 3 months should be asked about their pattern of injecting during this period, to determine their risk levels and the best course of intervention.

PATTERN OF INJECTING

INTERVENTION GUIDELINES

Once weekly or less or

Fewer than 3 days in a row

Brief Intervention including “risks

associated with injecting” card

More than once per week or

3 or more days in a row

Further assessment and more intensive treatment*

Hint

Time's up

FREE AND QUICK ONLINE CONFIDENTIAL SELF-SCREENING

MOOD DISORDER SELF-SCREENING TOOL

Welcome to your Mood Disorder Questionnaire

Instructions: Please answer each question to the best of your ability.

QUESTION 1. Has there ever been a period of time when you were not your usual self and...

Alcohol-AUDIT-Screening-tool

Welcome to your AUDIT Alcohol Screening Tool

Answer the following questions about your alcohol use during the past 12 months.

‘Select’ one box that best describes your answer to each question. Answer as accurately as you can.

When you have completed the questions SCORE them and put your total score in the box.

Thank you.

BAI test (Beck Anxiety Inventory)

Welcome to your Beck Anxiety Inventory (BAI) Test

Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by circling the number in the corresponding space in the column next to each symptom.

Burnout Self-Test

Welcome to your Burnout Self-Test

Instructions: For each question, place the corresponding number in the column that most applies.

Fagerstrom test

Welcome to your Fagerstrom Test for Nicotine Dependence

Instruction: Please select one for each of the questions.

ACE test for children

Welcome to your Adverse Childhood Experience (ACE) Questionnaire

This can be very helpful in the success of your treatment. While you were growing up, during your first 18 years of life:

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

Welcome to your Patient Health Questionnaire (PHQ-9)

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

Child and Adolescent Trauma Screen (CATS)-Youth Report

Welcome to your Child and Adolescent Trauma Screen (CATS)-Youth Report(7-17 years) Screening

Stressful or scary events happen to many people. Below is a list of stressful and scary events that sometimes happen. Mark YES if it happened to you. Mark No if it didn’t happen to you.

The following section has Questions about all the scary or stressful events that happened to you.Mark 0, 1, 2 or 3 for how often the following things have bothered you in the last two weeks:Never=0 / Once in a while=1 / Half the time=2 / Almost always=3

For the following set of questions, Please mark “YES” or “NO” if the problems you marked interfered with:

ADHD DSM-5 Checklist

Welcome to your ADHD DSM-5 Checklist Screening

For each item below, select the answer that best describes this child. 0=Not at all; 1=Just a Little; 2=Often; 3= Very Often

Inattention Symptoms

Hyperactive Symptoms

Impulsive Symptoms

WHO-ASSIST_V3.0

Welcome to your WHO-ASSIST_V3.0

NOTE: BEFORE ASKING QUESTIONS, GIVE ASSIST RESPONSE CARD TO PATIENT

Question 1

(if completing follow-up please cross-check the patient’s answers with the answers given for Q1 at baseline. Any differences on this question should be queried)

In your life, which of the following substances have you ever used? (NON-MEDICAL USE ONLY)

Probe if all answers are negative:“Not even when you were in school?”If "No" to all items, stop interview.If "Yes" to any of these items, ask Question 2 foreach substance ever used.

Question 2

In the past three months, how often have you used the substances you mentioned (FIRST DRUG, SECOND DRUG, ETC)?

If "Never" to all items in Question 2, skip to Question 6.If any substances in Question 2 were used in the previous three months, continue with Questions 3, 4 & 5 for each substance used.

Question 3

During the past three months, how often have you had a strong desire or urge to use (FIRST DRUG, SECOND DRUG, ETC)?

Question 4

During the past three months, how often has your use of (FIRST DRUG, SECOND DRUG, ETC) led to health, social, legal or financial problems?

Question 5

During the past three months, how often have you failed to do what was normally expected of you because of your use of (FIRST DRUG, SECOND DRUG, ETC)?

Ask Questions 6 & 7 for all substances ever used (i.e. those endorsed in Question 1)

Question 6

Has a friend or relative or anyone else ever expressed concern about your use of(FIRST DRUG, SECOND DRUG, ETC.)?

Question 7

Have you ever tried and failed to control, cut down or stop using (FIRST DRUG, SECOND DRUG, ETC.)?

Question 8

IMPORTANT NOTE:Patients who have injected drugs in the last 3 months should be asked about their pattern of injecting during this period, to determine their risk levels and the best course of intervention.

Stay Connected.

We'd love to hear from you on our social networks.Use the following mediums to learn more and give your valuable suggestions.

©2024 LIFEBRIDGE HOSPITAL

This can be very helpful in the success of your treatment.
While you were growing up, during your first 18 years of life:

The following section has Questions about all the scary or stressful events that happened to you.
Mark 0, 1, 2 or 3 for how often the following things have bothered you in the last two weeks:
Never=0 / Once in a while=1 / Half the time=2 / Almost always=3

For the following set of questions,
Please mark “YES” or “NO” if the problems you marked interfered with:

For each item below, select the answer that best describes this child.
0=Not at all; 1=Just a Little; 2=Often; 3= Very Often

Probe if all answers are negative:
“Not even when you were in school?”

If "No" to all items, stop interview.
If "Yes" to any of these items, ask Question 2 for
each substance ever used.

If "Never" to all items in Question 2, skip to Question 6.
If any substances in Question 2 were used in the previous three months, continue with Questions 3, 4 & 5 for each substance used.

Has a friend or relative or anyone else ever expressed concern about your use of
(FIRST DRUG, SECOND DRUG, ETC.)?

IMPORTANT NOTE:
Patients who have injected drugs in the last 3 months should be asked about their pattern of injecting during this period, to determine their risk levels and the best course of intervention.

We'd love to hear from you on our social networks.
Use the following mediums to learn more and give your valuable suggestions.