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BARIATRIC
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Binge Eating Disorder Screening Tool BEDS-7
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Excessive eating episodes in the last 3 months
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Do you feel distressed about these episodes?
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How often did you feel like you had no control over your eating
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How often did you continue eating even though you were not hungry?
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How often were you embarassed by how much you ate?
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How often did you feel disgusted or angry with yourself or guilty afterward?
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How often did you make yourself vomit or used laxatives as a means to control your weight or shape?
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Counseling Referral
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Sleep Apnea Screen
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Sleep Apnea Screening Tool
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Diagnosis of Sleep Apnea
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Last Sleep Study was
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New Short Text Field
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Uses medical device (CPAP, Bi-Pap, other)
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If yes, Current CPAP cmH2O Level:
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Does not have a formal diagnosis of sleep apnea
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Snoring
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Snoring
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choking sounds while sleeping
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choking sounds while sleeping
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Stopping breathing while sleeping
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Sleep apnea
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Fall asleep at inappropriate times
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Inappropriate falling asleep
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Most comfortable sleep position
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Most comfortable sleep
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Examiner comments
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MENTAL HEALTH
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MENTAL HEALTH
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ADHD Screen
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Attention
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Makes careless mistakes
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Poor attention
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Poor concentration
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Wrapping up
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Organizing
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Procrastinating
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Misplacing things
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Distractible
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Misses Appointments or obligations
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Total Inattention Score
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Hyperactivity
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Fidgety
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Cannot sit still for normal periods of time
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Restless
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Unwinding
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Motor
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Talking too much
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Finishes Sentences
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impatient (e.g, waiting in line for turn)
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Interrupts others
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Total Hyperactivity Score
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Depression
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Depression - PHQ-9 symptoms in the last 2 weeks
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Loss of Interest?
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Feeling down, depressed or hopeless?
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Trouble Sleeping?
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Feeling tired or having little energy?
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Poor appetite or overeating?
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Feeling bad about oneself?
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Trouble Concentrating?
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Feeling slowed down or fidgety & restless?
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Wanting to die or self harm?
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Difficulty of these problems?
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PHQ9 Scoring
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Negative Depression Screen
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Positive Depression Screen
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Anxiety Screen - GAD 7
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Over the last 2 weeks, how often have you been bothered by the following problems?
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1. Feeling nervous, anxious or on edge
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2. Not being able to stop or control worrying
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3. Worrying too much about different things
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4. Trouble relaxing
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5. Being so restless that it is hard to sit still
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6. Becoming easily annoyed or irritable
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7. Feeling afraid as if something awful might happen
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Total Sum of 1 - Several Days
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Total Sum of 2 - More than half the days
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Total Sum of 3 - Nearly every day
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Total Score
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Mood Disorder Screening Tool
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Mood History
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You felt so good or so hyper that other people thought you were not your normal self or so hyper that you got into trouble?
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You were so irritable that you shouted at people or started fights or arguments?
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You felt much more self confident than usual?
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You got much less sleep than usual and found you didn't really miss it?
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You were uncharacteristically more talkative or spoke more rapidly than usual.
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Thoughts raced through your head or you couldn't slow your mind down?
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You were so easily distracted by things around you that you had trouble concentrating or staying on track?
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You had much more energy than usual?
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You were much more active or did more things than usual?
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You were much more social or outgoing than normal, for example, you telephoned friends in the middle of the night
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Have you had periods of time where you were much more sexually interested than usual?
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Have you done things that were uncharacteristically excessive, foolish, or risky?
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Have you had periods of time where you spent money excessively causing financial hardship for you or your family?
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Mood clusters
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If you answered yes to any of the above have several of these behaviors been present during the same period of time?
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How much of a problem did any of these behaviors cause?
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Do you have any blood relatives with Bipolar Disorder or Manic Depression?
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Family members with Bipolar Disorder or Manic Depression.
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Has any health professional told you that you have Bipolar Disorder or Manic Depression?
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Which health professionals and when were you told ?
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Referral for Mood Disorder Workup
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