Wellness Check-in | Fidelis Care

The following questions are standard questions we ask all patients here at Fidelis Care so we can best understand how you are doing. We understand that some questions may not apply to you. Please bear with us and answer the questions to the best of your ability that matches your current health state. If you are a caregiver, please answer the questions as they relate to the Fidelis Care member identified below.

Name

First Last

Below are some statements that people sometimes make when they talk about their health. Please indicate how much you agree or disagree with each statement as it applies to you.

When all is said and done, I am the person who is responsible for managing my health condition*

Taking an active role in my own health care is the most important factor in determining my health and ability to function*

I am confident that I can take actions that will help prevent or minimize some symptoms or problems associated with my health condition*

I am confident that I can tell when I need to go get medical care and when I can handle a health problem myself*

Please check the answer that comes closest to how you have felt IN THE PAST 2 WEEKS, not just how you feel today. Over the past 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things*

Not at all
Several Days
More than half the days
Nearly every day

Feeling down, depressed or hopeless*

Not at all
Several Days
More than half the days
Nearly every day

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

Have you ever felt that you ought to cut down on your drinking or drug use?*

Yes
No

Have people annoyed you by criticizing your drinking or drug use?*

Yes
No

Have YOU ever felt bad or guilty about your drinking or drug use?*

Yes
No

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?*

Yes
No

Are you currently engaged in a substance dependence treatment program?*

Yes
No

What is the name of your substance dependence treatment program?*

Do you feel less dependent on substances?*

Yes
Somewhat
No
Not Sure

Do you want someone to reach out to you with options for your substance dependence?*

Yes
Somewhat
No

Hidden

PAM Score*

Hidden

PHQ2 Suicidal Score

Hidden

PHQ2 Depression Score

Hidden

CAGE AID

Hidden

REHAB ASSISTANCE

Hidden

region

Hidden

county

Hidden

mobile

Hidden

status

Hidden

EscalationEmail