Track 2 – Functional Health – Patient Self-Report Assessments


Functional Health – Patient Self-Report Assessments

Please answer all questions honestly and completely. All fields are required.

Patient Information



Please enter your full name.


Please enter your date of birth.


Please enter today’s date.

Pittsburgh Sleep Quality Index (PSQI)

Questions relate to your usual sleep habits during the past month only.

1.What time have you usually gone to bed at night?


Required.

2.How long (in minutes) has it usually taken you to fall asleep each night?


Required.

3.What time have you usually gotten up in the morning?


Required.

4.How many hours of actual sleep do you get at night?


Required.

5.During the past month, how often have you had trouble sleeping because you…
0 = Not during the past month  |  1 = Less than once a week  |  2 = Once or twice a week  |  3 = Three or more times a week
Sleep difficulty 0 1 2 3

Please rate all sleep difficulties.

6.How often have you taken medicine to help you sleep?



Required.

7.How often have you had trouble staying awake while driving, eating meals, or engaging in social activity?



Required.

8.How much of a problem has it been to keep up enough enthusiasm to get things done?



Required.

9.How would you rate your sleep quality overall?



Required.

PSQI Score

–

PHQ-9 Depression Scale

Over the last 2 weeks, how often have you been bothered by any of the following?
0 = Not at all  |  1 = Several days  |  2 = More than half the days  |  3 = Nearly every day

Problem 0
Not at all		 1
Several days		 2
>Half days		 3
Nearly every day

Please answer all PHQ-9 questions.

PHQ-9 Score

–

GAD-7 Anxiety Scale

Over the last 2 weeks, how often have you been bothered by the following?
0 = Not at all  |  1 = Several days  |  2 = More than half the days  |  3 = Nearly every day

Problem 0
Not at all		 1
Several days		 2
>Half days		 3
Nearly every day

Please answer all GAD-7 questions.

GAD-7 Score

–

Fatigue Severity Scale (FSS)

Rate each statement based on your experience over the past week. 1 = Strongly Disagree  |  7 = Strongly Agree

Please rate all fatigue statements.

FSS Score (Mean)

–

COMPASS-31 Autonomic Symptom Scale

The following questions assess symptoms of autonomic (automatic nervous system) dysfunction across 6 domains. Answer based on your experience over the past year.

Neuro-QoL Cognitive Function Short Form

In the past 7 days, how often did you have difficulty with the following?  |  1 = Never  2 = Rarely  3 = Sometimes  4 = Often  5 = Always

Difficulty 1
Never		 2
Rarely		 3
Sometimes		 4
Often		 5
Always

Please answer all Neuro-QoL questions.

Neuro-QoL Raw Score

–

✅

Thank you!

Your intake form has been submitted. Your provider will review your responses.