ANXIETY TEST

Over the last two weeks, how often have you been bothered by the following problems?
Please note, all fields are required for this screen.

1. Feeling nervous, anxious, or on edge

Not at all Several days More than half the days Nearly every day
2. Not being able to sleep or control worrying

Not at all Several days More than half the days Nearly every day
3. Worrying too much about different things
Not at all Several days More than half the days Nearly every day
4. Trouble relaxing

Not at all Several days More than half the days Nearly every day
5. Being so restless that it is hard to sit still

Not at all Several days More than half the days Nearly every day
6. Becoming easily annoyed or irritable

Not at all Several days More than half the days Nearly every day
7. Feeling afraid, as if something awful might happen

Not at all Several days More than half the days Nearly every day

DEPRESSION TEST
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Please note, all fields are required.

1. Little interest or pleasure in doing things

Not at all Several days More than half the days Nearly every day
2. Feeling down, depressed, or hopeless

Not at all Several days More than half the days Nearly every day
3. Trouble falling or staying asleep, or sleeping too much

Not at all Several days More than half the days Nearly every day
4. Feeling tired or having little energy

Not at all Several days More than half the days Nearly every day
5. Poor appetite or overeating
Not at all Several days More than half the days Nearly every day
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down

Not at all Several days More than half the days Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television

Not at all Several days More than half the days Nearly every day
8. Moving or speaking so slowly that other people could have noticed

Not at all Several days More than half the days Nearly every day
Or the opposite - being so fidgety or restless that you have been moving around a lot more than
usual
9. Thoughts that you would be better off dead, or of hurting yourself

Not at all Several days More than half the days Nearly every day
10. If you checked off any problems, how difficult have these problems made it for you at work, home, or with
other people?

Not difficult at all Somewhat difficult Very difficult Extremely difficult

 ADDICTION TEST
CAGE-AID Questionnaire
When thinking about your addiction issues including alcohol, drug use (include illegal
drug use and the use of prescription drug use other than prescribed) or other addiction,
Have you ever felt that you ought to cut down on your drinking or drug use?
Yes No
Have people annoyed you by criticizing your drinking or drug use?
Yes No
Have you ever felt bad or guilty about your drinking or drug use?
Yes No
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to
get rid of a hangover?
Yes No
What substance or addiction are you concerned about?
Alcohol

Marijuana

Cocaine/Crack

Heroin

Prescription Opioids

Stimulants (e.g. Speed, Meth, Prescription Stims)

Benzodiazepines (e.g. Xanax, Valium)

Tobacco

Cutting

Other (e.g. gambling, sex, internet, shopping, food, etc.)

 PTSD TEST
In your life, have you ever had any experience that was so frightening, horrible, or
upsetting that, in the past month, you...
Please note, all fields are required.
1. Have had nightmares about it or thought about it when you did not want to?
No Yes
2. Tried hard not to think about it or went out of your way to avoid situations that reminded
you of it?
No Yes
3. Were constantly on guard, watchful, or easily startled?
No Yes
4. Felt numb or detached from others, activities, or your surroundings?
No Yes
 YOUTH TEST
Paediatric Symptom Checklist - Youth Report
Please mark under the heading that best fits you.
Complain of aches or pains
Never Sometimes Often
Spend more time alone
Never Sometimes Often
Tire easily, little energy
Never Sometimes Often
Fidgety, unable to sit still
Never Sometimes Often
Have trouble with teacher
Never Sometimes Often
Less interested in school
Never Sometimes Often
Act as if driven by motor
Never Sometimes Often
Daydream too much
Never Sometimes Often
Distract easily
Never Sometimes Often
Are afraid of new situations
Never Sometimes Often
Feel sad, unhappy
Never Sometimes Often
Are irritable, angry
Never Sometimes Often
Feel hopeless
Never Sometimes Often
Have trouble concentrating
Never Sometimes Often
Less interested in friends
Never Sometimes Often
Fight with other children
Never Sometimes Often
Absent from school
Never Sometimes Often
School grades dropping
Never Sometimes Often
Down on yourself
Never Sometimes Often
Visit doctor with doctor finding nothing wrong
Never Sometimes Often
Have trouble sleeping
Never Sometimes Often
Worry a lot
Never Sometimes Often
Want to be with parent more than before
Never Sometimes Often
Feel that you are bad
Never Sometimes Often
Take unnecessary risks
Never Sometimes Often
Get hurt frequently
Never Sometimes Often
Seem to be having less fun
Never Sometimes Often
Act younger than children your age
Never Sometimes Often
Do not listen to rules
Never Sometimes Often
Do not show feelings
Never Sometimes Often
Do not understand other people's feelings
Never Sometimes Often
Tease others
Never Sometimes Often
Blame others for your troubles
Never Sometimes Often
Take things that do not belong to you
Never Sometimes Often
Refuse to share
Never Sometimes Often
Do you have any emotional or behavioural problems for which you need help?
No Yes
 PARENT TEST
Paediatric Symptom Checklist
Please mark under the heading that best describes your child.
Feels sad, unhappy
Never Sometimes Often
Feels hopeless
Never Sometimes Often
Is down on self
Never Sometimes Often
Worries a lot
Never Sometimes Often
Seems to be having less fun
Never Sometimes Often
Fidgety, unable to sit still
Never Sometimes Often
Daydreams too much
Never Sometimes Often
Distracted easily
Never Sometimes Often
Has trouble concentrating
Never Sometimes Often
Acts as if driven by a motor
Never Sometimes Often
Fights with other children
Never Sometimes Often
Does not listen to rules
Never Sometimes Often
Does not understand other people’s feelings
Never Sometimes Often
Teases others
Never Sometimes Often
Blames others for his/her troubles
Never Sometimes Often
Refuses to share
Never Sometimes Often
Takes things that do not belong to him/her
Never Sometimes Often