ScreeningsPlease complete the surveys below Name * First Name Last Name Review of Systems * Check any new or worsening symptoms Fever, chills, sweating Headache, dizziness, confusion, weakness, tingling, pins and needles Drainage or bleeding from ears, eyes, nose, or throat; change in senses Chest pain, chest tightness, fluttering in the chest, breast pain, nipple discharge Cough, shortness of breath, difficulty catching your breath Nausea, vomiting, diarrhea, constipation, heartburn, abdominal pain Change in urination, difficulty urinating, frequent UTIs, pelvic discharge, pelvic pain Extremity swelling, weakness, or masses Skin bumps, pimples, rashes, discoloration, or cuts that won't heal Other None Depression Screening In the last 2 weeks have you felt the following symptoms 0 (not at all), 1 (some of the time), 2 (most of the time), or 3 (all of the time)? Little interest or pleasure in doing things * 0 1 2 3 Feeling down, depressed, or hopeless * 0 1 2 3 Trouble falling asleep, staying asleep, or sleeping too much * 0 1 2 3 Feeling tired or having little energy * 0 1 2 3 Poor appetite or overeating * 0 1 2 3 Feeling bad about yourself, that you are a failure, or you have let yourself or your family down * 0 1 2 3 Trouble concentrating on things such as reading an article or watching TV * 0 1 2 3 Moving or speaking so slowly that other people have noticed, or the opposite, being so restless and fidgety that people have noticed * 0 1 2 3 Thoughts that you would be better off dead or hurting yourself in some way * 0 1 2 3 Sleep Apnea Screening * Do you/are you (check all that apply)? Snore Wake up tired wanting to go back to bed Stop breathing while sleeping Have high blood pressure Male Have a body mass index (BMI) over 35 Over 50 years old Have a neck/collar >16in None of these Thank you, your responses have been recorded!
