Online Behavioral Health Screening

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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
Prepopulate Answers: False
Response Code Status: True
Response Id: 0
Seed Response Id:


Please answer the following survey questions:
Question Order: 0
Required: True
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3987
Answer Count: 2
Prepopulate Answer: False
Gender * Required

Question Type Id: 3
Answer Id: 10345
Answer Text: Female
Answer Type Id: 0
Female

Question Type Id: 3
Answer Id: 10346
Answer Text: Male
Answer Type Id: 0
Male
Question Order: 1
Required: True
Question Type Id: 5
Question Answer Type Id: 0
Question Id: 3592
Answer Count: 0
Prepopulate Answer: False
1. Age (please enter numbers only) * Required
Question Order: 2
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3488
Answer Count: 5
Prepopulate Answer: False
2. How would you describe your overall health during the past month?

Question Type Id: 3
Answer Id: 9231
Answer Text: 1. Excellent
Answer Type Id: 0
1. Excellent

Question Type Id: 3
Answer Id: 9232
Answer Text: 2. Very Good
Answer Type Id: 0
2. Very Good

Question Type Id: 3
Answer Id: 9233
Answer Text: 3. Good
Answer Type Id: 0
3. Good

Question Type Id: 3
Answer Id: 9234
Answer Text: 4. Fair
Answer Type Id: 0
4. Fair

Question Type Id: 3
Answer Id: 9235
Answer Text: 5. Poor
Answer Type Id: 0
5. Poor
Question Order: 3
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3489
Answer Count: 5
Prepopulate Answer: False
3. During the past month how much have physical or emotional problems interfered in your work, school, family activities or social activities?

Question Type Id: 3
Answer Id: 9236
Answer Text: 1. Not at All
Answer Type Id: 0
1. Not at All

Question Type Id: 3
Answer Id: 9237
Answer Text: 2. Slightly
Answer Type Id: 0
2. Slightly

Question Type Id: 3
Answer Id: 9238
Answer Text: 3. Moderately
Answer Type Id: 0
3. Moderately

Question Type Id: 3
Answer Id: 9239
Answer Text: 4. Quite a Bit
Answer Type Id: 0
4. Quite a Bit

Question Type Id: 3
Answer Id: 9240
Answer Text: 5. Extremely
Answer Type Id: 0
5. Extremely
Question Order: 4
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3490
Answer Count: 5
Prepopulate Answer: False
4. Have you had difficulty with managing pain over the past month?

Question Type Id: 3
Answer Id: 9241
Answer Text: 1. None
Answer Type Id: 0
1. None

Question Type Id: 3
Answer Id: 9242
Answer Text: 2. Very Mild
Answer Type Id: 0
2. Very Mild

Question Type Id: 3
Answer Id: 9243
Answer Text: 3. Mild
Answer Type Id: 0
3. Mild

Question Type Id: 3
Answer Id: 9244
Answer Text: 4. Moderate
Answer Type Id: 0
4. Moderate

Question Type Id: 3
Answer Id: 9245
Answer Text: 5. Severe
Answer Type Id: 0
5. Severe
Question Order: 5
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3491
Answer Count: 5
Prepopulate Answer: False
5. Has the pain you experienced impacted your activities with work, school, family or social engagements?

Question Type Id: 3
Answer Id: 9246
Answer Text: 1. No
Answer Type Id: 0
1. No

Question Type Id: 3
Answer Id: 9247
Answer Text: 2. A Little
Answer Type Id: 0
2. A Little

Question Type Id: 3
Answer Id: 9248
Answer Text: 3. Moderately
Answer Type Id: 0
3. Moderately

Question Type Id: 3
Answer Id: 9249
Answer Text: 4. A Lot
Answer Type Id: 0
4. A Lot

Question Type Id: 3
Answer Id: 9250
Answer Text: 5. Severely
Answer Type Id: 0
5. Severely
Question Order: 7
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3492
Answer Count: 5
Prepopulate Answer: False
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?

Question Type Id: 3
Answer Id: 9252
Answer Text: 1-No
Answer Type Id: 0
1-No

Question Type Id: 3
Answer Id: 9253
Answer Text: 2-Two or three occasions
Answer Type Id: 0
2-Two or three occasions

Question Type Id: 3
Answer Id: 9493
Answer Text: 3-Four or five occasions
Answer Type Id: 0
3-Four or five occasions

Question Type Id: 3
Answer Id: 9494
Answer Text: 4-Every two or three days
Answer Type Id: 0
4-Every two or three days

Question Type Id: 3
Answer Id: 9495
Answer Text: 5-Daily
Answer Type Id: 0
5-Daily
Question Order: 8
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3493
Answer Count: 10
Prepopulate Answer: False
7. In the past few weeks, what is your level of stress on a scale between one and ten?

Question Type Id: 3
Answer Id: 9256
Answer Text: 1-Low Stress
Answer Type Id: 0
1-Low Stress

Question Type Id: 3
Answer Id: 9257
Answer Text: 2
Answer Type Id: 0
2

Question Type Id: 3
Answer Id: 9258
Answer Text: 3
Answer Type Id: 0
3

Question Type Id: 3
Answer Id: 9259
Answer Text: 4
Answer Type Id: 0
4

Question Type Id: 3
Answer Id: 9260
Answer Text: 5
Answer Type Id: 0
5

Question Type Id: 3
Answer Id: 9261
Answer Text: 6
Answer Type Id: 0
6

Question Type Id: 3
Answer Id: 9262
Answer Text: 7
Answer Type Id: 0
7

Question Type Id: 3
Answer Id: 9263
Answer Text: 8
Answer Type Id: 0
8

Question Type Id: 3
Answer Id: 9264
Answer Text: 9
Answer Type Id: 0
9

Question Type Id: 3
Answer Id: 9265
Answer Text: 10-High Stress
Answer Type Id: 0
10-High Stress
Question Order: 9
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3494
Answer Count: 10
Prepopulate Answer: False
8. In the past few weeks what is your ability to cope with everyday problems on a scale of one to ten?

Question Type Id: 3
Answer Id: 9266
Answer Text: 1-Low Coping
Answer Type Id: 0
1-Low Coping

Question Type Id: 3
Answer Id: 9267
Answer Text: 2
Answer Type Id: 0
2

Question Type Id: 3
Answer Id: 9268
Answer Text: 3
Answer Type Id: 0
3

Question Type Id: 3
Answer Id: 9269
Answer Text: 4
Answer Type Id: 0
4

Question Type Id: 3
Answer Id: 9270
Answer Text: 5
Answer Type Id: 0
5

Question Type Id: 3
Answer Id: 9271
Answer Text: 6
Answer Type Id: 0
6

Question Type Id: 3
Answer Id: 9272
Answer Text: 7
Answer Type Id: 0
7

Question Type Id: 3
Answer Id: 9273
Answer Text: 8
Answer Type Id: 0
8

Question Type Id: 3
Answer Id: 9274
Answer Text: 9
Answer Type Id: 0
9

Question Type Id: 3
Answer Id: 9275
Answer Text: 10-High Coping
Answer Type Id: 0
10-High Coping
Question Order: 10
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3495
Answer Count: 4
Prepopulate Answer: False
9. Over the past month, how often have you experienced little pleasure in doing things you normally enjoy?

Question Type Id: 3
Answer Id: 9276
Answer Text: 1. Not at All
Answer Type Id: 0
1. Not at All

Question Type Id: 3
Answer Id: 9277
Answer Text: 2. Several Days
Answer Type Id: 0
2. Several Days

Question Type Id: 3
Answer Id: 9278
Answer Text: 3. More than Half the Days
Answer Type Id: 0
3. More than Half the Days

Question Type Id: 3
Answer Id: 9279
Answer Text: 4. Nearly Every Day
Answer Type Id: 0
4. Nearly Every Day
Question Order: 11
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3496
Answer Count: 4
Prepopulate Answer: False
10. During the past month how often have you felt down or hopeless?

Question Type Id: 3
Answer Id: 9280
Answer Text: 1. Not at All
Answer Type Id: 0
1. Not at All

Question Type Id: 3
Answer Id: 9281
Answer Text: 2. Several Days
Answer Type Id: 0
2. Several Days

Question Type Id: 3
Answer Id: 9282
Answer Text: 3. More than Half the Days
Answer Type Id: 0
3. More than Half the Days

Question Type Id: 3
Answer Id: 9283
Answer Text: 4. Nearly Every Day
Answer Type Id: 0
4. Nearly Every Day
Question Order: 12
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3497
Answer Count: 2
Prepopulate Answer: False
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?

Question Type Id: 3
Answer Id: 9284
Answer Text: 1. No
Answer Type Id: 0
1. No

Question Type Id: 3
Answer Id: 9285
Answer Text: 2. Yes
Answer Type Id: 0
2. Yes
Question Order: 13
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3498
Answer Count: 2
Prepopulate Answer: False
12. In the past three months have you tried to control your weight or lose weight by not eating for 24 hours or more?

Question Type Id: 3
Answer Id: 9286
Answer Text: 1. No
Answer Type Id: 0
1. No

Question Type Id: 3
Answer Id: 9287
Answer Text: 2. Yes
Answer Type Id: 0
2. Yes
Question Order: 14
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3499
Answer Count: 2
Prepopulate Answer: False
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?

Question Type Id: 3
Answer Id: 9288
Answer Text: 1. No
Answer Type Id: 0
1. No

Question Type Id: 3
Answer Id: 9289
Answer Text: 2. Yes
Answer Type Id: 0
2. Yes
Question Order: 15
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3500
Answer Count: 2
Prepopulate Answer: False
14. If you tried to control your weight with the activities above, would it happen twice a week or more?

Question Type Id: 3
Answer Id: 9290
Answer Text: 1. No
Answer Type Id: 0
1. No

Question Type Id: 3
Answer Id: 9291
Answer Text: 2. Yes
Answer Type Id: 0
2. Yes
Question Order: 16
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3501
Answer Count: 5
Prepopulate Answer: False
15. How often did you have a drink containing alcohol in the past year?

Question Type Id: 3
Answer Id: 9292
Answer Text: 1. Never
Answer Type Id: 0
1. Never

Question Type Id: 3
Answer Id: 9293
Answer Text: 2. Monthly or Less
Answer Type Id: 0
2. Monthly or Less

Question Type Id: 3
Answer Id: 9294
Answer Text: 3. Two to four times a month
Answer Type Id: 0
3. Two to four times a month

Question Type Id: 3
Answer Id: 9295
Answer Text: 4. Two to three times a week
Answer Type Id: 0
4. Two to three times a week

Question Type Id: 3
Answer Id: 9296
Answer Text: 5. Four or more times a week
Answer Type Id: 0
5. Four or more times a week
Question Order: 17
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3502
Answer Count: 5
Prepopulate Answer: False
16. How many drinks did you have on a typical day when you were drinking in the past year?

Question Type Id: 3
Answer Id: 9297
Answer Text: 1. One or two
Answer Type Id: 0
1. One or two

Question Type Id: 3
Answer Id: 9298
Answer Text: 2. Three or four
Answer Type Id: 0
2. Three or four

Question Type Id: 3
Answer Id: 9299
Answer Text: 3. Five or six
Answer Type Id: 0
3. Five or six

Question Type Id: 3
Answer Id: 9300
Answer Text: 4. Seven to nine
Answer Type Id: 0
4. Seven to nine

Question Type Id: 3
Answer Id: 9301
Answer Text: 5. Ten or more
Answer Type Id: 0
5. Ten or more
Question Order: 18
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3503
Answer Count: 5
Prepopulate Answer: False
17. How often did you have five or more drinks on one occasion in the past year?

Question Type Id: 3
Answer Id: 9302
Answer Text: 1-Never
Answer Type Id: 0
1-Never

Question Type Id: 3
Answer Id: 9303
Answer Text: 2-Less than Monthly
Answer Type Id: 0
2-Less than Monthly

Question Type Id: 3
Answer Id: 9304
Answer Text: 3-Monthly
Answer Type Id: 0
3-Monthly

Question Type Id: 3
Answer Id: 9305
Answer Text: 4-Weekly
Answer Type Id: 0
4-Weekly

Question Type Id: 3
Answer Id: 9306
Answer Text: 5-Daily or Almost Daily
Answer Type Id: 0
5-Daily or Almost Daily
Question Order: 21
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3505
Answer Count: 2
Prepopulate Answer: False
18. Do you have any friends who drank beer, wine or any drink containing alcohol in the past year?

Question Type Id: 3
Answer Id: 9312
Answer Text: 1. Yes
Answer Type Id: 0
1. Yes

Question Type Id: 3
Answer Id: 9313
Answer Text: 2. No
Answer Type Id: 0
2. No
Question Order: 22
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3506
Answer Count: 2
Prepopulate Answer: False
19. How about you? Have you ever had more than a few sips of beer, wine or any drink containing alcohol?

Question Type Id: 3
Answer Id: 9314
Answer Text: 1. Yes
Answer Type Id: 0
1. Yes

Question Type Id: 3
Answer Id: 9315
Answer Text: 2. No
Answer Type Id: 0
2. No
Question Order: 23
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3577
Answer Count: 5
Prepopulate Answer: False
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?

Question Type Id: 3
Answer Id: 9411
Answer Text: 1. 1-5
Answer Type Id: 0
1. 1-5

Question Type Id: 3
Answer Id: 9412
Answer Text: 2. 6-11
Answer Type Id: 0
2. 6-11

Question Type Id: 3
Answer Id: 9413
Answer Text: 3. 12-23
Answer Type Id: 0
3. 12-23

Question Type Id: 3
Answer Id: 9414
Answer Text: 4. 24-51
Answer Type Id: 0
4. 24-51

Question Type Id: 3
Answer Id: 9415
Answer Text: 5. 52+
Answer Type Id: 0
5. 52+
Question Order: 24
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3578
Answer Count: 5
Prepopulate Answer: False
21. If your friends drink, how many drinks do they usually have at one time?

Question Type Id: 3
Answer Id: 9417
Answer Text: 1. One
Answer Type Id: 0
1. One

Question Type Id: 3
Answer Id: 9418
Answer Text: 2. Two
Answer Type Id: 0
2. Two

Question Type Id: 3
Answer Id: 9419
Answer Text: 3. Three
Answer Type Id: 0
3. Three

Question Type Id: 3
Answer Id: 9420
Answer Text: 4. Four
Answer Type Id: 0
4. Four

Question Type Id: 3
Answer Id: 9421
Answer Text: 5. Five or more
Answer Type Id: 0
5. Five or more
Question Order: 25
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3579
Answer Count: 5
Prepopulate Answer: False
22. In the past three months how often have you used tobacco?

Question Type Id: 3
Answer Id: 9422
Answer Text: 1. Never
Answer Type Id: 0
1. Never

Question Type Id: 3
Answer Id: 9423
Answer Text: 2. Once or Twice
Answer Type Id: 0
2. Once or Twice

Question Type Id: 3
Answer Id: 9424
Answer Text: 3. Monthly
Answer Type Id: 0
3. Monthly

Question Type Id: 3
Answer Id: 9425
Answer Text: 4. Weekly
Answer Type Id: 0
4. Weekly

Question Type Id: 3
Answer Id: 9426
Answer Text: 5. Daily or Almost Daily
Answer Type Id: 0
5. Daily or Almost Daily
Question Order: 26
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3580
Answer Count: 5
Prepopulate Answer: False
23. How many times in the past three months have you used prescription medications (greater than prescribed or not prescribed)

Question Type Id: 3
Answer Id: 9427
Answer Text: 1. Never
Answer Type Id: 0
1. Never

Question Type Id: 3
Answer Id: 9428
Answer Text: 2. Once or Twice
Answer Type Id: 0
2. Once or Twice

Question Type Id: 3
Answer Id: 9429
Answer Text: 3. Monthly
Answer Type Id: 0
3. Monthly

Question Type Id: 3
Answer Id: 9430
Answer Text: 4. Weekly
Answer Type Id: 0
4. Weekly

Question Type Id: 3
Answer Id: 9431
Answer Text: 5. Daily or Almost Daily
Answer Type Id: 0
5. Daily or Almost Daily
Question Order: 27
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3581
Answer Count: 5
Prepopulate Answer: False
24. How many times in the past three months have you used mood or mind altering substances not prescribed by a physician?

Question Type Id: 3
Answer Id: 9432
Answer Text: 1. Never
Answer Type Id: 0
1. Never

Question Type Id: 3
Answer Id: 9433
Answer Text: 2. Once or Twice
Answer Type Id: 0
2. Once or Twice

Question Type Id: 3
Answer Id: 9434
Answer Text: 3. Monthly
Answer Type Id: 0
3. Monthly

Question Type Id: 3
Answer Id: 9435
Answer Text: 4. Weekly
Answer Type Id: 0
4. Weekly

Question Type Id: 3
Answer Id: 9436
Answer Text: 5. Daily or Almost Daily
Answer Type Id: 0
5. Daily or Almost Daily
Question Order: 28
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3588
Answer Count: 3
Prepopulate Answer: False
25. Has a relative, friend, or anyone else ever said they are concerned about your use of drugs?

Question Type Id: 3
Answer Id: 9467
Answer Text: 1. No, never.
Answer Type Id: 0
1. No, never.

Question Type Id: 3
Answer Id: 9468
Answer Text: 2. Yes, in the past threee months.
Answer Type Id: 0
2. Yes, in the past threee months.

Question Type Id: 3
Answer Id: 9469
Answer Text: 3. Yes, but not in the past three months.
Answer Type Id: 0
3. Yes, but not in the past three months.
Question Order: 29
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3589
Answer Count: 5
Prepopulate Answer: False
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?

Question Type Id: 3
Answer Id: 9470
Answer Text: 1. Never
Answer Type Id: 0
1. Never

Question Type Id: 3
Answer Id: 9471
Answer Text: 2. Once or Twice
Answer Type Id: 0
2. Once or Twice

Question Type Id: 3
Answer Id: 9472
Answer Text: 3. Monthly
Answer Type Id: 0
3. Monthly

Question Type Id: 3
Answer Id: 9473
Answer Text: 4. Weekly
Answer Type Id: 0
4. Weekly

Question Type Id: 3
Answer Id: 9474
Answer Text: 5. Daily or Almost Daily
Answer Type Id: 0
5. Daily or Almost Daily
Question Order: 30
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3590
Answer Count: 4
Prepopulate Answer: False
27. Do you take any prescribed medications which may interact negatively with the substances you have used?

Question Type Id: 3
Answer Id: 9475
Answer Text: 1. No prescribed medications
Answer Type Id: 0
1. No prescribed medications

Question Type Id: 3
Answer Id: 9476
Answer Text: 2. Don't know
Answer Type Id: 0
2. Don't know

Question Type Id: 3
Answer Id: 9477
Answer Text: 3. Yes, one medication
Answer Type Id: 0
3. Yes, one medication

Question Type Id: 3
Answer Id: 9478
Answer Text: 4. Yes, multiple medications
Answer Type Id: 0
4. Yes, multiple medications
Question Order: 31
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3984
Answer Count: 2
Prepopulate Answer: False
28.During the past 12 months, have you become restless, irritable or anxious when trying to stop/cut down on gambling?

Question Type Id: 3
Answer Id: 10339
Answer Text: Yes
Answer Type Id: 0
Yes

Question Type Id: 3
Answer Id: 10340
Answer Text: No
Answer Type Id: 0
No
Question Order: 32
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3985
Answer Count: 2
Prepopulate Answer: False
29. During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled?

Question Type Id: 3
Answer Id: 10343
Answer Text: Yes
Answer Type Id: 0
Yes

Question Type Id: 3
Answer Id: 10344
Answer Text: No
Answer Type Id: 0
No
Question Order: 33
Required: False
Question Type Id: 3
Question Answer Type Id: 0
Question Id: 3986
Answer Count: 2
Prepopulate Answer: False
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?

Question Type Id: 3
Answer Id: 10341
Answer Text: Yes
Answer Type Id: 0
Yes

Question Type Id: 3
Answer Id: 10342
Answer Text: No
Answer Type Id: 0
No
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