Tools

Depression Self-Screener
Determining whether or not the symptoms you're experiencing are tied to depression can be difficult. This questionnaire, provided by Mental Health America, allows you to determine whether you have symptoms of depression.  This confidential screening consists of nine questions that ask you to evaluate your thoughts, feelings, and behaviors over the past two weeks, and helps to indicate whether or not you should seek additional help from your healthcare provider.

Symptom Log
Keeping track of symptoms on a regular basis can help patients become more aware of their symptoms and understand how other factors in their life may be affecting symptoms. This tool also encourages patients to make healthy changes and observe how these may affect their health. This sample symptom log developed by a person with a long-term condition, who is also a nurse, is for recording symptoms and can be shared with health care providers.

Doc Talk Form
Patient and family advisors from the Medical College of Georgia Health System developed this simple form to help patients and their families organize their thoughts and information in preparation for a healthcare visit. The forms are printed into notepads and are available in the reception area of ambulatory clinics.

My Shared Care Plan
My Shared Care Plan was developed in partnership with health care professionals and patients. The tool offers patients with long-term conditions and their families a way to keep track of their health and healthcare. It includes ways to identify and track goals and other information that patients and families believe will help them self-manage more effectively. My Shared Care Plan also assists people in sharing information with their health care provider.

Self Management Support
This form, developed at Improving Chronic Illness Care program in Seattle Washington, helps people with chronic conditions develop a personal plan to learn a new behavior, such as starting a program to increase their physical activity.

The Healthy Changes Plan form may be used by patients either at home or during their office visit to plan their self-management goals for managing their chronic condition.

Conviction Confidence Ruler
This tool helps patients and providers discuss and rate two issues related to goal setting and healthy changes – how convinced a patient is that the change is necessary or important and how confident they are in their ability to achieve the goal.

Action Plan
This short form helps people with chronic conditions develop and record changes they plan to make or goals they want to achieve. The form can be used during a health care visit and then copied so the patient has a copy to take home. It can also be included in their chart to support follow-up. An example of a completed form is included.