Wellness Assessment – AdultPlease enable JavaScript in your browser to complete this form.We respect your privacy. Your answers are confidential and will not be given to your employer or any clinician who has not provided care to you. We will review your answers to see if we can offer you additional resources or support. We may also review your answers with your clinician if doing so could help you. We encourage you to complete this form and discuss with your clinician. If you have questions about this form, please call the number on the back of your enrollee card. INSTRUCTIONS FOR COMPLETING THE WELLNESS ASSESSMENT This form is for clients 18 or older Select one answer per question. Directions for Clinicians: Please review the completed assessment with your client. Check to be sure that all member and clinician identifying information at the top of the form is complete and accurate. Clinician ID refers to your tax id. In the event that a member is unable to complete this form, please complete both the patient and clinician information and fill in the "MRef" option next to "Clinician ID". Submit this form This form is a secure, confidential assessment. Completing this brief questionnaire will help us provide services that meet your needs. Answer each question as best you can and then review your responses with your clinician.Name *FirstLastDate of BirthSubscriber IDAuthorization #Clinician Name *FirstLastToday's DateClinician ID/ Tax IDClinician Phone NumberMRefMRefStateVisit Number1 or 23 to 5OtherFor questions 1-16, please think about your experience in the past week.How much did the following problems bother you?1. Nervousness or Shakiness Not at AllA littleSomewhatA Lot2. Feeling sad or blueNot at AllA littleSomewhatA Lot3. Feeling hopeless about the futureNot at AllA littleSomewhatA Lot4. Feeling everything is an effortNot at AllA littleSomewhatA Lot5. Feeling no interest in thingsNot at AllA littleSomewhatA Lot6. Your heart pounding or racingNot at AllA littleSomewhatA Lot7. Trouble sleepingNot at AllA littleSomewhatA Lot8. Feeling fearful or afraidNot at AllA littleSomewhatA Lot9. Difficulty at homeNot at AllA littleSomewhatA Lot10. Difficulty sociallyNot at AllA littleSomewhatA Lot11. Difficulty at work or schoolNot at AllA littleSomewhatA LotHow much do you agree with the following?12. I feel good about myselfStrongly AgreeAgreeDisagreeStrongly Disagree13. I can deal with my problemsStrongly AgreeAgreeDisagreeStrongly Disagree14. I am able to accomplish the things I wantStrongly AgreeAgreeDisagreeStrongly Disagree15. I have friends or family that I can count on for helpStrongly AgreeAgreeDisagreeStrongly Disagree16. In the past week, approximately how many drinks of alcohol did you have?Please answer the following questions only if this is your first time completing this questionnaire.17. In general, would you say your health isExcelleteVery GoodGoodFairPoor18. Please indicate if you have a serious or chronic medical conditionAsthmaDiabetesHeart DiseaseBack Pain or Other Chronic PainOther19. In the past 6 months, how many times did you visit a medical doctor?None12-34-56+20. In the past month, how many days were you unable to work because of your physical or mental health? (answer only if employed)21. In the past month, how many days were you able to work but had to cut back on how much you got done because of your physical or mental health? (answer only if employed)22. In the past month have you ever felt you ought to cut down on your drinking or drug use?YesNo23. In the past month have you ever felt annoyed by people criticizing your drinking or drug use?YesNo24. In the past month have you felt bad or guilty about your drinking or drug use?YesNoSubmit