Online Behavioral Health Screening

Please complete the following questions and press "Submit." You will be shown a summary page with suggestions for next steps based on the answers you have submitted. Please begin by entering your age. If you are completing the screening for a minor, please enter their age. Some questions are evaluated based on the age of the person completing the screening.
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https://surveys.ndbh.com/Survey/External/9cb571
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Member Name: Anonymous

User Info:
Survey Id: 169
Representative user Id that is taking this survey on behalf of a member: 2
Context Id of representative taking survey: 6
Member Id: 0
Context Id of Member: 6
Program Id (if appropriate): 0


Please answer the following survey questions:
Gender * Required
Female
Male
1. Age (please enter numbers only) * Required
2. How would you describe your overall health during the past month?
1. Excellent
2. Very Good
3. Good
4. Fair
5. Poor
3. During the past month how much have physical or emotional problems interfered in your work, school, family activities or social activities?
1. Not at All
2. Slightly
3. Moderately
4. Quite a Bit
5. Extremely
4. Have you had difficulty with managing pain over the past month?
1. None
2. Very Mild
3. Mild
4. Moderate
5. Severe
5. Has the pain you experienced impacted your activities with work, school, family or social engagements?
1. No
2. A Little
3. Moderately
4. A Lot
5. Severely
6. In the past month, have you had to increase your medications (over-the-counter or prescribed) beyond the recommended dose in order to tolerate your pain?
1-No
2-Two or three occasions
3-Four or five occasions
4-Every two or three days
5-Daily
7. In the past few weeks, what is your level of stress on a scale between one and ten?
1-Low Stress
2
3
4
5
6
7
8
9
10-High Stress
8. In the past few weeks what is your ability to cope with everyday problems on a scale of one to ten?
1-Low Coping
2
3
4
5
6
7
8
9
10-High Coping
9. Over the past month, how often have you experienced little pleasure in doing things you normally enjoy?
1. Not at All
2. Several Days
3. More than Half the Days
4. Nearly Every Day
10. During the past month how often have you felt down or hopeless?
1. Not at All
2. Several Days
3. More than Half the Days
4. Nearly Every Day
11. In the past three months have you tried to control your weight or lose weight by using more than the recommended dose of laxatives?
1. No
2. Yes
12. In the past three months have you tried to control your weight or lose weight by not eating for 24 hours or more?
1. No
2. Yes
13. In the past three months have you tried to control your weight or lose weight by exercising for more than an hour because you ate too much?
1. No
2. Yes
14. If you tried to control your weight with the activities above, would it happen twice a week or more?
1. No
2. Yes
15. How often did you have a drink containing alcohol in the past year?
1. Never
2. Monthly or Less
3. Two to four times a month
4. Two to three times a week
5. Four or more times a week
16. How many drinks did you have on a typical day when you were drinking in the past year?
1. One or two
2. Three or four
3. Five or six
4. Seven to nine
5. Ten or more
17. How often did you have five or more drinks on one occasion in the past year?
1-Never
2-Less than Monthly
3-Monthly
4-Weekly
5-Daily or Almost Daily
18. Do you have any friends who drank beer, wine or any drink containing alcohol in the past year?
1. Yes
2. No
19. How about you? Have you ever had more than a few sips of beer, wine or any drink containing alcohol?
1. Yes
2. No
20. In the past year, on how many days have you had more than a few sips of beer, wine or any drink containing alcohol?
1. 1-5
2. 6-11
3. 12-23
4. 24-51
5. 52+
21. If your friends drink, how many drinks do they usually have at one time?
1. One
2. Two
3. Three
4. Four
5. Five or more
22. In the past three months how often have you used tobacco?
1. Never
2. Once or Twice
3. Monthly
4. Weekly
5. Daily or Almost Daily
23. How many times in the past three months have you used prescription medications (greater than prescribed or not prescribed)
1. Never
2. Once or Twice
3. Monthly
4. Weekly
5. Daily or Almost Daily
24. How many times in the past three months have you used mood or mind altering substances not prescribed by a physician?
1. Never
2. Once or Twice
3. Monthly
4. Weekly
5. Daily or Almost Daily
25. Has a relative, friend, or anyone else ever said they are concerned about your use of drugs?
1. No, never.
2. Yes, in the past threee months.
3. Yes, but not in the past three months.
26. During the past three months have you had difficulty being successful at work, at school, or in your relationships because of the drugs you have used?
1. Never
2. Once or Twice
3. Monthly
4. Weekly
5. Daily or Almost Daily
27. Do you take any prescribed medications which may interact negatively with the substances you have used?
1. No prescribed medications
2. Don't know
3. Yes, one medication
4. Yes, multiple medications
28.During the past 12 months, have you become restless, irritable or anxious when trying to stop/cut down on gambling?
Yes
No
29. During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled?
Yes
No
30. During the past 12 months did you have such financial trouble as a result of your gambling that you had to get help with living expenses from family, friends or welfare?
Yes
No
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