GAIN-SS Telemed Appt Date of your Appointment MM slash DD slash YYYY Person who has the appointment name First Last Who is your appointment with? Dr. Kefalas Angela Pellerito Dannielle Nelson I am not sure GAIN-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 future Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Had sleep trouble, such as bad dreams, sleeping restlessly or falling asleep during the day Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Felt very anxious, nervous, tense, scared, panicked or like something bad was going to happen Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Became very distressed and upset when something reminded you of the past Past Month – 4 2-3 Months- 3 4-12 Months – 2 1+ year – 1 Never Thought about ending your life or committing suicide Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Saw or heard things that no one else could see or hear or felt that someone else could read or control your thoughts Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never EDSscrLied or conned to get things you wanted or to avoid having to do something Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Had a hard time paying attention at school, work, or home Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Had a hard time listening to instruction at school, work, or home Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Had a hard time waiting your turn Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Were a bully or threatened other people Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Started a physical fight with other people Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Tried to win back your gambling losses by going back another day Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never SDSscrUsed alcohol or other drugs weekly or more often….. Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or recovering from the effects of alcohol or other drugs Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never You kept using alcohol or other drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Your use of alcohol or other drugs caused you to give up or reduce your involvement in activities at work, school, home, or social events Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never You 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 problems Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never CVSscrHad a disagreement in which you pushed, grabbed, or shoved someone Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Took something from a store without paying for it Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Sold, distributed, or helped to make illegal drugs Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Drove a vehicle while under the influence of alcohol or illegal drugs Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Purposely damaged or destroyed property that did not belong to you Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never Do 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
