First Responders Questionnaire - PRIME Medical Group PLLC

Wellness
Self-Check Questionnaire

Please fill out the form as completely and accurately as possible as all the information is important in determining effective strategies for your therapy program.

Step 1 of 6 - Patient Information

WELCOME!

This is a safe, easy way to learn whether stress and depression might be affecting you and how you can receive support through our Military and First Responder Program.

This form is intended for the patient and their immediate family. Using this service is completely voluntary, anonymous and confidential. No information will be shared with the with your employer.

This is not an emergency response system or crisis intervention service. If you have recently thought about suicide, or are currently thinking about suicide, please call 911.

DON'T SUFFER ALONE!

What happens next?

Our Medical Team will review your Questionnaire and post a personal response to you on this secure website. The response will include information, recommendations, and options for next steps.

You decide what's next. You'll have the option of communicating with our Medical Team through the platform, on the phone or in person. Or, you can decide to do nothing further at this time.

It's up to you. No follow-up services will be provided unless requested.

PROTECTING YOUR PRIVACY

You'll have to of providing your contact information on your Questionnaire. Your email address will be HIPPA compliant system and will not be revealed to anyone, including the counselor. As further protection, you may wish to set up a new email account (e.g. gmail, yahoo, aol) that does not contain any part of your first or last name. If you don't give an email address, at the completion of the Self-Check Questionnaire you'll be told when to return to this website to get the counselor's response.

Questions? Contact Us at 312-554-5013 or Continue below.

In the last 4 weeks, have you experienced any of the following as a result of a traumatic of disturbing experience that occurred at any point in your life:

Have had nightmares about it or thought about it when you did not want to(Required)

Yes

Tried hard not to think about it or went out of your way to avoid situations that remind you of it(Required)

Yes

Were constantly on guard, watchful or easily started(Required)

Yes

Felt numb or detached from others, activities or your surroundings(Required)

Yes

During the last 4 weeks, how often have you been bothered by any of the following:

Feeling nervous or worrying a lot(Required)

Not at all

Sometimes

Most or all of the time

Becoming easily annoyed or irritable(Required)

Not at all

Sometimes

Most of the time

Feeling your life is too stressful(Required)

Not at all

Sometimes

Most of the time

Having arguments or fights(Required)

Not at all

Sometimes

Most of the time

Feeling intensely anxious or having anxiety attacks(Required)

Not at all

Sometimes

Most of the time

Feeling intensely lonely(Required)

Not at all

Sometimes

Most of the time

Feeling intensely angry(Required)

Not at all

Sometimes

Most of the time

Feeling hopeless(Required)

Not at all

Sometimes

Most of the time

Feeling desperate(Required)

Not at all

Sometimes

Most of the time

Feeling out of control(Required)

Not at all

Sometimes

Most of the time

During the last 4 weeks, how often have you experienced any of the following:

Drinking alcohol (including beer or wine) more than usual(Required)

Not at all

Sometimes

Most of the time

Feeling like you were drinking too much(Required)

Not at all

Sometimes

Most of the time

Feeling that your work attendance or performance was affected by your drinking(Required)

Not at all

Sometimes

Most of the time

Using drugs other than alcohol (marijuana, cocaine, etc.) or taking prescription medications without medical supervision(Required)

Not at all

Sometimes

Most of the time

Thinking about the last 2 weeks, how often have you been bothered by any of the following problems? Please note: The answers require you to make precise choices which are important to understand what you are experiencing. Please be patient.

Feeling tired or having little energy(Required)

Not at all

Sometimes

A lot of the time

Most of the time

Having trouble falling or staying asleep, or sleeping too much(Required)

Not at all

Sometimes

A lot of the time

Most of the time

Having a poor appetite or overeating(Required)

Not at all

Sometimes

A lot of the time

Most of the time

Having trouble concentrating on things, such as reading newspaper or watching television(Required)

Not at all

Sometimes

A lot of the time

Most of the time

Feeling bad about yourself - or that you are a failure or have let yourself or your family down(Required)

Not at all

Sometimes

A lot of the time

Most of the time

Moving or speaking so slowly that other people could have noticed? Or the opposite - being so restless that you have been moving around a lot more than usual(Required)

Not at all

Sometimes

A lot of the time

Most of the time

Feeling a lack of interest or pleasure in doing things(Required)

Not at all

Sometimes

A lot of the time

Most of the time

Feeling down or depressed(Required)

Not at all

Sometimes

A lot of the time

Most of the time

Having thoughts that you would be better off dead or thoughts of physically harming yourself(Required)

Not at all

Sometimes

A lot of the time

Most of the time

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

Had thoughts about taking your own life?(Required)

Not at all

Sometimes

Most or all of the time

Planned ways of taking your own life?(Required)

Not at all

Sometimes

Most or all of the time

Done things to hurt yourself?(Required)

Not at all

Sometimes

Most or all of the time

In your lifetime..... Have you ever made a suicide attempt?(Required)

Not at all

Sometimes

Most or all of the time

Have you ever been knocked out or unconscious following an accident or injury?(Required)

Yes

If you checked off any problems on this Questionnaire, how difficult have these problems make it for you to do work, take care of things at home, or get along with other people?(Required)

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

If you checked off any problems on this Questionnaire, how difficult have these problems make it for you to do work, take care of things at home, or get along with other people?(Required)

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Are you currently...

Taking any medication for pain?(Required)

Yes

Taking any medication for stress?(Required)

Yes

Taking any medication for anxiety?(Required)

Yes

Taking any medication for depression?(Required)

Yes

Getting counseling or therapy?(Required)

Yes

Please take a minute to let us know about anything that might be contributing to how you are feeling at the time - a job-related incident or situation, a family problem, financial stress, a health issue, relationship stress or breakup, death or a loved one or any other type of loss or significant change. Anything you tell us is confidential. The more detailed your response, the better able we'll be to understand and assist you.(Required)

Age

Remember, you may wish to set up a new email account (e.g. gmail, yahoo, aol) that does not contain any part of your first or last name.

Comments

This field is for validation purposes and should be left unchanged.

Wellness
Self-Check Questionnaire

WELCOME!

PROTECTING YOUR PRIVACY

During the last 4 weeks, how often have you been bothered by any of the following:

During the last 4 weeks, how often have you experienced any of the following:

Thinking about the last 2 weeks, how often have you been bothered by any of the following problems? Please note: The answers require you to make precise choices which are important to understand what you are experiencing. Please be patient.

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

Are you currently...

Remember, you may wish to set up a new email account (e.g. gmail, yahoo, aol) that does not contain any part of your first or last name.

PRIME Medical group PLLC

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WellnessSelf-Check Questionnaire

WELCOME!

PROTECTING YOUR PRIVACY

During the last 4 weeks, how often have you been bothered by any of the following:

During the last 4 weeks, how often have you experienced any of the following:

Thinking about the last 2 weeks, how often have you been bothered by any of the following problems? Please note: The answers require you to make precise choices which are important to understand what you are experiencing. Please be patient.

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

Are you currently...

Remember, you may wish to set up a new email account (e.g. gmail, yahoo, aol) that does not contain any part of your first or last name.

Wellness
Self-Check Questionnaire