GAIN-SS Telemed Appt Date of your Appointment Date Format: MM slash DD slash YYYY Person who has the appointment name First Last Who is your appointment with?Dr. KefalasAngela PelleritoDannielle NelsonI am not sureGAIN-SSPlease check the box next to the number that tells us how long ago you experienced each of the following... IDSscrFelt trapped, lonely, sad, depressed, blue, or hopeless about the futurePast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverHad sleep trouble, such as bad dreams, sleeping restlessly or falling asleep during the dayPast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverFelt very anxious, nervous, tense, scared, panicked or like something bad was going to happenPast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverBecame very distressed and upset when something reminded you of the pastPast Month - 42-3 Months- 34-12 Months - 21+ year - 1NeverThought about ending your life or committing suicidePast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverSaw or heard things that no one else could see or hear or felt that someone else could read or control your thoughtsPast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverEDSscrLied or conned to get things you wanted or to avoid having to do somethingPast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverHad a hard time paying attention at school, work, or homePast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverHad a hard time listening to instruction at school, work, or homePast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverHad a hard time waiting your turnPast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverWere a bully or threatened other peoplePast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverStarted a physical fight with other peoplePast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverTried to win back your gambling losses by going back another dayPast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverSDSscrUsed alcohol or other drugs weekly or more often…..Past Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverSpent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or recovering from the effects of alcohol or other drugsPast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverYou kept using alcohol or other drugs even though it was causing social problems, leading to fights, or getting you into trouble with other peoplePast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverYour use of alcohol or other drugs caused you to give up or reduce your involvement in activities at work, school, home, or social eventsPast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverYou had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still or sleeping, or you used any alcohol or other drugs to stop being sick or avoid withdrawal problemsPast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverCVSscrHad a disagreement in which you pushed, grabbed, or shoved someonePast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverTook something from a store without paying for itPast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverSold, distributed, or helped to make illegal drugsPast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverDrove a vehicle while under the influence of alcohol or illegal drugsPast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverPurposely damaged or destroyed property that did not belong to youPast Month - 42-3 Months - 34-12 Months - 21+ year - 1NeverDo you have other significant psychological, behavioral or personal problems that you want treatment for or help with? If yes, please describe:Consent By clicking this box, I agree that that the information is true and accurate to the best of my knowledge.Email
