Appendix A. Online Risk Assessment Tool - AHRQ National ...

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1 Have you been diagnosed with any of the following conditions? Check all that apply:1 Have you been diagnosed with any of the following conditions? Check all that apply:1 Have you been diagnosed with any of the following conditions? Check all that apply:of the following conditions? Check all that apply:2 Do you take medications for any of the following conditions? Check all that apply:2 Do you take medications for any of the following conditions? Check all that apply:2 Do you take medications for any of the following conditions? Check all that apply:2 Do you take medications for any of the following conditions? Check all that apply:Psychiatric# Question PrereqSub-Question Options Points Script(s)Have you been diagnosedwith any of the followingconditions? Check all that1 apply: Depression Depression1 Have you been diagnosed with any of the following conditions? Check all that apply:Anxiety AnxietyBipolarBipolarDisorderDisorderSchizophrenia SchizophreniaNone of theaboveDo you take medications forany of the followingconditions? Check all that2 apply: Depression Prescriptions2 Do you take medications for anyAnxiety PrescriptionsBipolarDisorderPrescriptionsSchizophrenia PrescriptionsOther mentalhealthconditionPrescriptionsNone of theaboveHas anyone in your family oryour partner’s family beendiagnosed with any of theFamily Historyfollowing conditions? Checkof psychiatric3 all that apply:Depressioncondition3 Has anyone in your family or your partner’s family been diagnosed with any of the following conditions? Check all that apply:Anxiety3 Has anyone in your family or your partner’s family been diagnosed with any of the following conditions? Check all that apply:3 Has anyone in your family or your partner’s family been diagnosed with any of the following conditions? Check all that apply:Schizophrenia3 Has anyone in your family or your partner’s family been diagnosed with any of the following conditions? Check all that apply:4In the last 2 weeks, how oftenhave you been bothered byany of the followingproblems?Several4 In the last 2 weeks , how often have you been bothered by any of the following problems? Little interest or pleasure in doing things4 In the last 2 weeks , how often have you been bothered by any of the following problems? Little interest or pleasure in doing things4 In the last 2 weeks , how often have you been bothered by any of the following problems? Little interest or pleasure in doing thingsBipolarDisorderNone of theaboveLittle interestor pleasure indoing things Not at all 0days 1More thanhalf the days 2Nearly everyday 3Family Historyof psychiatricconditionFamily Historyof psychiatricconditionFamily Historyof psychiatricconditionDepression=positive fromscreeningtool, but notdiagnosedProgrammingNotesPositive Score>5 when 4-4iare combined10
Psychiatric (continued)# Question Prereq4aIn the last 2 weeks, how oftenhave you been bothered byany of the followingproblems?4a Feeling down, depressed, or hopeless.Several4a4a5Sub-Question Options Points Script(s)Feeling down,depressed, orhopeless. Not at all 0days 1More thanFeeling down, depressed, or hopeless.half the days 2Nearly everyday 3Feeling down, depressed, or hopeless.In the last month, how oftenhave you felt that you wereunable to control theimportant things in your life? Never 0Almost5 In the last month , how often have you felt that you were unable to control the important things in your life?Sometimes5 In the last month , how often have you felt that you were unable to control the important things in your life?Fairly5 In the last month , how often have you felt that you were unable to control the important things in your life?Very5 In the last month , how often have you felt that you were unable to control the important things in your life?6never 12often 3often 4In the last month, how oftenhave you felt confident aboutyour ability to handle yourpersonal problems? Never 4Almost6 In the last month , how often have you felt confident about your ability to handle your personal problems?Sometimes6 In the last month , how often have you felt confident about your ability to handle your personal problems?Fairly6 In the last month , how often have you felt confident about your ability to handle your personal problems?Very6 In the last month , how often have you felt confident about your ability to handle your personal problems?7never 32often 1often 0In the last month, how oftenhave you felt that things weregoing your way? Never 4Almost7 In the last month , how often have you felt that things were going your way?Sometimes7 In the last month , how often have you felt that things were going your way?Fairly7 In the last month , how often have you felt that things were going your way?Very7 In the last month , how often have you felt that things were going your way?8never 32often 1often 0In the last month, how oftenhave you felt difficulties werepiling up so high that youcould not overcome them? Never 0ProgrammingNotesIf patient answers"more than halfthe days or nearlyevery day toeither of the firsttwo, continue torest of screening.Or STOP ifanswers "not atall" or "severaldays" to BOTH.For 5-8, a scoreof 8 or morewould lead to thestress scriptAlmost never 18 In the last month , how often have you felt difficulties were piling up so high that you could not overcome them?Sometimes 28 In the last month , how often have you felt difficulties were piling up so high that you could not overcome them?Fairly often 38 In the last month , how often have you felt difficulties were piling up so high that you could not overcome them?Very often 48 In the last month , how often have you felt difficulties were piling up so high that you could not overcome them?Sources: Adapted from Jack BW, Culpepper L, Babcock J, Kogan MD, Weismiller D. Addressing Preconception <strong>Risk</strong>s Identifiedat the Time of a Negative Pregnancy Test. A Randomized Trial. J Fam Pract. 1998;47(1)33-38. PHQ-9 Depression Scale:Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001Sep;16(9):606-13. Perceived Stress Scale: Cohen S. Retrieved from: http://www.psy.cmu.edu/~scohen/. Reviewed by ArielaFriedler, MD; Peter S. Bernstein, MD, MPH11
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Page 3 and 4: 2 Do you use birth control on a reg
Page 5 and 6: Sexual and reproductive health (con
Page 7 and 8: 6 Do you take any prescriptions for
Page 9: Family and genetic history (continu
Page 13 and 14: Immunizations (continued)# Question
Page 15 and 16: Infectious disease (continued)# Que
Page 17 and 18: Infectious disease (continued)# Que
Page 19 and 20: Nutrition and activity# Question Pr
Page 21 and 22: Environmental exposures# Question P

Appendix A. Online Risk Assessment Tool - AHRQ National ...

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