form11 FR0349 UBH Wellness Adult ALERT® Wellness Assessment - Youth ■ Completing this brief questionnaire will help us provide services that meet your child's needs. Answer each question as best you can and then review your responses with your child's clinician.Client Name First Last Date of Birth MM slash DD slash YYYY Subscriber ID Authorization NumberClinician Name First Last Todays Date MM slash DD slash YYYY Clinician ID/Tax ID Clinician PhoneState State Visit #1 or 23 to 5otherFor the next questions, please think about your experience in the past weekHow much did the following problems bother you?Nervousness or shakiness Not at all A Little Somewhat Alot Feeling sad or blue Not at all A Little Somewhat Alot Feeling hopeless about the future Not at all A Little Somewhat Alot Feeling everything is an effort Not at all A Little Somewhat Alot Feeling no interest in things Not at all A Little Somewhat Alot Your heart pounding or racing Not at all A Little Somewhat Alot Trouble sleeping Not at all A Little Somewhat Alot Feeling fearful or afraid Not at all A Little Somewhat Alot Difficulty at home Not at all A Little Somewhat Alot Difficulty socially Not at all A Little Somewhat Alot Difficulty at work or school Not at all A Little Somewhat Alot Section BreakHow much do you agree with the following?I feel good about myself Strongly Agree Agree Disagree Strongly disagree I can deal with my problems Strongly Agree Agree Disagree Strongly disagree I am able to accomplish the things I want Strongly Agree Agree Disagree Strongly disagree I have friends or family that I can count on for help Strongly Agree Agree Disagree Strongly disagree In the past week, approximately how many drinks of alcohol did you have?Section BreakIs this your first time completing this questionnaire Yes No In general, would you say your health is: Excellent Very Good Good Fair Poor Please indicate if you have a serious or chronic medical condition: Asthma Diabetes Heart Disease Back Pain or Other Chronic Pain Other Condition In the past 6 months, how many times did you visit a medical doctor? None 1 2-3 4-5 6+ In the past month, how many days were you unable to work because of your physical or mental health? (answer only if employedIn 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)In the past month have you ever felt you ought to cut down on your drinking or drug use? Yes No In the past month have you ever felt annoyed by people criticizing your drinking or drug use? Yes No In the past month have you felt bad or guilty about your drinking or drug use? Yes No ■ Clinician: Please fax to (800) 985-6894 Rev. 2007
