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New York Provider Manual
VII-C Guidelines for Adolescent Preventive Services (GAPS) | VII-E Healthfirst Wellness Reward Card - PHSP

Appendix VII-D — Primary Care Provider Behavioral Health Screening Tool

**This questionnaire is intended exclusively as a screening device and is NOT a substitute for a complete Behavioral Health evaluation and assessment. All answers will remain confidential.

QUESTION
YES
NO
I
1.    Over the past month, have you had decreased interest or pleasure in doing things that you usually enjoy?
 
 
2A.  Over the past month, have you been feeling down or depressed?
 
 
2B.  If yes, rate your mood most of the time over the past month, on a scale of 1 to 10 (1 = worst, 10 = best mood)
 
 
3.    Over the past month, has there been a change in your sleeping or eating habits or energy level, without any obvious explanation?
 
 
4.    Do you ever think about harming yourself or feel you might be better off dead?
 
 
5.    Over the past month have you experienced feelings of helplessness, hopelessness, or worthlessness?
 
 
II
6A.  Over the past month, have you often felt very nervous or anxious or have you been worrying about things for no good reason?
 
 
6B.  If yes, rate how anxious or nervous you felt most of the time, on a scale of 1 to 10 (1 = highly anxious, 10 =  relaxed).
 
 
7.    In the past month, have you had an anxiety attack (suddenly felt fear or panic)?
 
 
8.    Over the past month, have you ever had recurrent thoughts or rituals that interfere with your daily activities or make them difficult to complete?
 
 
III
9A.   Have you ever felt you ought to cut down on your drinking?
 
 
9B.   Have people annoyed you by criticizing your drinking?
 
 
9C.   Have you ever felt bad or guilty about your drinking?
 
 
9D.   Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)?
 
 
10A. Do you ever use illegal drugs?
 
 
10B. Approximately how often?
 
 
10C. What kind of drugs do you use?
 
 
11.   Has drinking or drug use ever interfered with work, home, school, or family responsibilities?
 
 
IV
12A. In the last three months, have you done any of the following to avoid gaining weight?
 
 
12B. Intentionally made yourself vomit?
 
 
12C. Taken laxatives regularly or excessively?
 
 
12D. Fasted for over 24 hours, for no other reason?
 
 
12E. Exercised excessively, for more than an hour at a time?
 
 
13A. In the past three months, have you ever had an episode of binge eating?
 
 
13B. If yes, approximately how many episodes have you experienced?
 
 
13C. Approximately how often have you experienced them?
 
 
V
14.   Over the past month, has there ever been a time when you heard voices when no one else was around or seen things that no one else saw?
 
 
15.   During the past month, have you ever had thoughts or feelings that someone wanted to hurt you or is out to get you?
 
 
16.   Do you believe that you have any special powers?
 
 
 
Patient’sName:___________________________________                                      DOB:__________________
 
Today’s Date: __________________                             

Primary Care Provider Behavioral Health Screening Tool Scoring Guide

 Questions 4 and 14, if answered in the affirmative, require immediate referral for urgent or emergent evaluation.
Section I
Depression questions 1–5:

Any three (3) or more questions answered in the affirmative or any two (2) or more questions answered in the affirmative with a mood severity rating of < 4 should be referred for further evaluation.
Section II
Anxiety/Panic/OCD questions 6–8:

Any two (2) questions or more answered in the affirmative or any one (1) question answered in the affirmative with an anxiety severity rating of < 4 should be referred for further evaluation.
Section III
Substance & Alcohol Use/Abuse questions 9–11:

Any two (2) or more questioned answered in the affirmative should be referred for further evaluation. Referral should also be made based on the severity assessment screening questions.
Section IV
Eating Disorders questions 12–13:

Any three (3) or more questions (question 12 counts as 4 questions) answered in the affirmative should be referred for further evaluation. Referral should also be made based on the severity assessment screening questions.
Section V
Perceptual Abnormalities/Psychotic Symptoms questions 14–16*:

Any two (2) or more questions answered in the affirmative should be referred for further evaluation.
If the total number of questions answered in the affirmative is equal to or greater than 10, regardless of the distribution/specific question answered or the severity reported, the patient should be referred for further evaluation.