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MM Follow Up + PHQ-9

1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Med Management Follow up visit

Name: Date of Birth: Date:

Are you taking medications as prescribed? YesNo

Comments:

How often do you miss a dose?

Time you go to bed:

Time you fall asleep:

How many times do you wake in the middle of the night?

Time you get up for the day?

Naps:

Please CHECK any of these you have had since your last visit:

Alcohol Cannabis Tobacco Caffeine Meth/cocaine Pain pills/heroin Other

Please CHECK any of these you have had since your last visit:

HEENT: headaches dry mouth blurred vision grinding/clenching teeth

Cardiac: heart palpitations racing heart chest pain

Respiratory: shortness of breath coughing wheezing

Stomach/bowel: nausea vomiting diarrhea constipation abdominal pain

Urinary: leakage hard to start stream burning frequent urge excessive urination

Musculoskeletal: joint pain muscle pain

Skin: rash itching excessive sweating acne hair loss excessive hair growth

Neuro: tremor/shakiness dizziness unsteadiness falls numbness/tingling slurred speech movements not done on purpose

Endocrine: change in sexual function change in menstrual cycle feeling too hot or too cold excessive thirst breast enlargement breast discharge

Blood/heme: easy bruising unusual bleeding

General: fever change in weight change in appetite

PHQ-9

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

Little interest or pleasure in doing things:

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

Feeling down, depressed or hopeless:

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

Trouble falling asleep, staying asleep or sleeping too much:

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

Feeling tired or having little energy:

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

Poor appetite or overeating:

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

Feeling bad about yourself, or that you are a failure or have let yourself or your family down:

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

Trouble concentrating on things such as reading or watching television:

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

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

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

Thoughts of that you would be better off dead, or of hurting yourself in some way:

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

If so, how likely are you to act on these thoughts? UnlikelyLikely

If you checked off any problems from this list, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at allSomewhat difficultVery difficultExtremely difficult

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Timestamp

Audit

March 8, 2023 8:48 am PDT

MM Follow Up + PHQ-9 Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202

March 17, 2023 12:22 pm PDT

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