Mental Health Intake & Symptom Assessment Packet

(PHQ-9 + GAD-7 + Functional Assessment)

Boris A. Khaimov, D.O. - Child, Adolescent & Adult Psychiatry

11 Grace Avenue, Suite 204, Great Neck, NY 11021 · 229 7th Street, Suite 305, Garden City, NY 11530

Progress

Please complete all sections below as thoroughly as possible. Fields marked * are required.

Patient Information

Patient First Name*

Patient Last Name*

Date of Birth*

Date of Birth is used to file this form with the correct patient record. (Not part of the original paper form.)

Date*

Section 1 - PHQ-9 (Depression Screening)

Over the last 2 weeks, how often have you been bothered by the following problems?*

Question	Not at all (0)	Several days (1)	> Half days (2)	Nearly daily (3)

Total Score (out of 27)

Severity

Functional Impact Question: How difficult have these problems made it for you to function?*

Not difficult Somewhat difficult Very difficult Extremely difficult

Section 2 - GAD-7 (Anxiety Screening)

Over the last 2 weeks, how often have you been bothered by the following?*

Question	Not at all (0)	Several days (1)	> Half days (2)	Nearly daily (3)

Total Score (out of 21)

Severity

Functional Impact Question: How difficult have these problems made it for you to function?*

Not difficult Somewhat difficult Very difficult Extremely difficult

Section 3 - Functional Assessment

Cognitive Function

Sleep

Hours per night

Energy & Motivation

Appetite & Metabolism

Emotional Regulation

Daily Functioning

Section 4 - Clinical Red Flags (High Yield)

Please check if present:

Passive death wish Active suicidal thoughts Prior suicide attempt Panic attacks Severe insomnia Substance use concerns

Section 5 - Metabolic Psychiatry Lens

Clinician Scoring Summary

For clinician completion.

PHQ-9: - → Severity: -

GAD-7: - → Severity: -

Functional Impairment

Calculated automatically from the PHQ-9 and GAD-7 functional impact questions above (whichever indicates greater impairment).

Your responses are sent securely to the practice. Nothing is stored in this browser.

Thank you

Your assessment has been received. Our office will follow up if anything further is needed.