Complete Adult Health History Form

Here at Trailhead Clinics we are sensitive to the growing concern of our mental health. We want to raise awareness and help develop a system that helps and responds to the overall well being for all. Depression can affect one in five adults and one in six youth aged 6 -17 each year. There is help and reaching out is that first step. Trailhead Clinics is offering a free mental health screening to help you find out if you could get some added support or point you in the right direction to receive care.
By checking this box I certify that I am 18 years of age or older and I reside in the State of Colorado. I am aware that it may take several business days to get back to me with my results and that this screening is not intended to treat or diagnose an urgent/emergent mental health condition. If I am concerned that I may harm myself or another person, I agree to call 911 or the Colorado Crisis Line at 1-844-493-8255 in order to get immediate help.*
- I Agree

Here at Trailhead Clinics we are sensitive to the growing concern of our mental health. We want to raise awareness and help develop a system that helps and responds to the overall well being for all. Depression can affect one in five adults and one in six youth aged 6 -17 each year. There is help and reaching out is that first step. Trailhead Clinics is offering a free mental health screening to help you find out if you could get some added support or point you in the right direction to receive care.
Patient Name:*
First Last
City:*
Patient Date of Birth:*
MM slash DD slash YYYY
Phone*
Email*

Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things.*
Feeling down, depressed, or hopeless.*
Trouble falling or staying asleep, or sleeping too much.*
Feeling tired or having little energy.*

Over the last 2 weeks, how often have you been bothered by any of the following problems?
Poor appetite or overeating.*
Feeling bad about yourself – or that you are a failure or have let yourself or your family down.*
Trouble concentrating on things, such as reading the newspaper or watching television.*
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.*
Thoughts that you would be better off dead, or of hurting yourself in some way.*

How difficult have these made it for you to do your work, take care of things at home, or get along with other people?
Name
This field is for validation purposes and should be left unchanged.

We CARE About Your Mental Health!