Sunbelt Wellness Institute is changing the way we provide relief for treatment-resistant conditions.
8833 Perimeter Park Blvd., Suite #1004
904.328.6749
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Home
About
Our Team
About Ketamine
Conditions
Ketamine
Pricing
Blog
Testimonials
Contact
Get In Touch
Provider Referral
Partner With Us
Patient Health Assessment
Sunbelt Wellness Institute is changing the way we provide relief for treatment-resistant conditions.
8833 Perimeter Park Blvd., Suite #1004
904.328.6749
Home
About
Our Team
About Ketamine
Conditions
Ketamine
Pricing
Blog
Testimonials
Contact
Get In Touch
Provider Referral
Partner With Us
Patient Health Assessment
Consultation
Patient Health Assessment
Home
Patient Health Assessment
Patient Health Assessment
Name
*
First
Last
Phone
*
Email
*
Over the past 2 weeks, how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things
*
Not At All
Several Days
More Than Half the Days
Nearly Every Day
2. Feeling down, depressed or hopeless
*
Not At All
Several Days
More Than Half the Days
Nearly Every Day
3. Trouble falling asleep, staying asleep, or sleeping too much
*
Not At All
Several Days
More Than Half the Days
Nearly Every Day
4. Feeling tired or having little energyExample label
*
Not At All
Several Days
More Than Half the Days
Nearly Every Day
5. Poor appetite or overeating
*
Not At All
Several Days
More Than Half the Days
Nearly Every Day
6. Feeling bad about yourself - or that you’re a failure or have let yourself or your family down Not At All
*
Not At All
Several Days
More Than Half the Days
Nearly Every Day
7. Trouble concentrating on things, such as reading the newspaper or watching television
*
Not At All
Several Days
More Than Half the Days
Nearly Every Day
8. Moving or speaking so slowly that other people could have noticed. Or, the opposite - being so fidgety or restless that you have been moving around a lot more than usual
*
Not At All
Several Days
More Than Half the Days
Nearly Every Day
9. Thoughts that you would be better off dead or of hurting yourself in some way
*
Not At All
Several Days
More Than Half the Days
Nearly Every Day
10. If you checked off any problems, how difficult have those problems made it for you to Do your work, take care of things at home, or get along with other people?
*
Not At All
Several Days
More Than Half the Days
Nearly Every Day
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