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[PDF File]Patient Health Questionnaire (PHQ-9)
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PATIENT HEALTH QUESTIONNAIRE (PHQ-9) NAME: DATE: Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several days More than half the days Nearly every day (use " ü " to indicate your answer) 1. Little interest or pleasure in doing things 0 1 2 3
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[PDF File]AUTHORIZATION, AGREEMENT B. Request Status …
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result of any failure on my part to meet the terms of this agreement may be withheld from any monies owed me by the Government, or may be recovered by such other methods as are approved by law. 5. I FURTHER AGREE to obtain approval from my organization and the person
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[PDF File]Form I-693, Report of Medical Examination and Vaccination ...
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Form I-693 07/15/19. Page 1 of 14. Report of Medical Examination and Vaccination Record . Department of Homeland Security . U.S. Citizenship and Immigration Services
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[PDF File]IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM HEALTH …
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least 12 consecutive months OR expected to result in death within 12 months? Please complete Items # 5 - 8, to the extent you are able, to further assist the IHSS worker in determining this individual’s eligibility. By signing this form, I certify that I am licensed in the State of California and all information provided above is correct. YES NO
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[PDF File]Edinburgh Postnatal Depression Scale (EPDS)
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Edinburgh Postnatal Depression Scale 1 (EPDS) Postpartum depression is the most common complication of childbearing. 2 The 10-question Edinburgh
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[PDF File]TINETTI BALANCE ASSESSMENT TOOL
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TINETTI BALANCE ASSESSMENT TOOL GAIT SECTION Patient stands with therapist, walks across room (+/- aids), first at usual pace, then at rapid pace. Risk Indicators: Tinetti Tool Score Risk of Falls ≤18 High 19-23 Moderate ≥24 Low Date Indication of gait (Immediately after told to ‘go’.) Any hesitancy or multiple attempts = 0 No hesitancy = 1
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[PDF File]VAMC SLUMS Examination - Saint Louis University
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ten minutes to eleven o’clock. Hour markers okay Time correct 10. Please place an X in the triangle. Which of the above figures is largest? 11. I am going to tell you a story. Please listen carefully because afterwards, I’m going to ask you some questions about it. Jill was a very successful stockbroker. She made a lot of money on the stock ...
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[PDF File]Oswestry Low Back Disability Questionnaire - Rehabilitation
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The Oswestry Disability Index (also known as the Oswestry Low Back Pain Disability Questionnaire) is an extremely important tool that researchers and disability evaluators use to measure a patient's permanent ... Oswestry Low Back Disability Questionnaire Author: Health and Rehabilitation unit
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[PDF File]COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS)
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A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in part thought of as method to kill oneself. Intent does not have to be 100%. If there is any intent/desire to die associated with the act, then it can be considered an actual suicide attempt.
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[PDF File]PRIVACY ACT STATEMENT THE AUTHORITY TO REQUEST THIS ...
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the authority to request this information is contained in 5 usc 301, and frim e.o. 9397 departmental regulations. the principle purpose of the information is to enable you to make know your desire for items listed or for some other special consideration or authorization. the information will be used to assist officials and employees of
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O l exam result