1 - Before we get started, how are you feeling today?*

2 - Over the past 2 weeks, how often have you been bothered by having little interest or pleasure in doing things?*

3 - Over the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?*

4 - Over the past 2 weeks, how often have you been bothered by trouble falling or staying asleep, or sleeping too much?*

5 - Over the past 2 weeks, how often have you been bothered by feeling tired or having little energy?*

6 - Over the past 2 weeks, how often have you been bothered by poor appetite or eating? *

7 - Over the past 2 weeks, how often have you been bothered by feeling bad about yourself, that you are a failure, or have let yourself or your family down?*

8 - Over the past 2 weeks, how often have you been bothered by trouble concentrating on things such as reading the newspaper or watching TV?*

9 - Over the past 2 weeks, how often have you been bothered by moving or speaking so slowly that other people have noticed, OR being so fidgety or restless that you have been moving around a lot more than usual?*

10 - Over the past 2 weeks, how often have you been bothered by feeling nervous, anxious, or on edge?*

11 - Over the past 2 weeks, how often have you been bothered by not being able to control worrying?*

12 - Over the past 2 weeks, how often have you been bothered by worrying too much about different things?*

13 - Over the past 2 weeks, how often have you been bothered by trouble relaxing?*

14 - Over the past 2 weeks, how often have you been bothered by being so restless that it is hard to sit still?*

15 - Over the past 2 weeks, how often have you been bothered by becoming easily annoyed or irritable?*

16 - Over the past 2 weeks, how often have you been bothered by feeling afraid as if something awful might happen?*

17 - "Over the past 2 weeks, how difficult has it been for you to do your work, take care of things at home, or get along with other people? "*

18 - When did the symptoms first begin?*

19 - Have you ever used any of the following mental health medications in the past?*

20 - Was your past treatment effective?

21 - Do you take any medicines, vitamins, or supplements?

22 - Do you smoke or use other tobacco products?*

23 - How many alcoholic beverages do you drink per week?*

24 - Have you had more than 5 drinks at one time in a row sometime over the past 30 days?*

25 - Have you been diagnosed with, or have a history of, any mental health conditions?

26 - "Do you have a family history of any mental health conditions? "*

27 - Do you have or have you ever had any of the following conditions?*

28 - Please list any additional medical conditions, surgeries, or hospitalizations you have had.

29 - Please list any allergies you have.

30 - Is there anything else related to the treatment that you'd like to ask or discuss with your medical provider?

31 - Do you have a preferred treatment? *

32 - Please enter preferred pharmacy information.*