Mississippi Health Screener

Doctor or Prescriber Zip Code

Patient Zip Code

What is your age?

• 12-17
• 18 or older

What is your sex?

• Male
• Female
• Prefer not to answer

How many children do you have that are 5 years old and younger?

• 0
• 1
• 2
• 3 or more

Are you pregnant?

• No
• Yes

During the past 12 months, how many days did you drink more than a few sips of beer, wine, or any drink containing alcohol?

• 0
• 1 or more

During the past 12 months, how many days did you use any marijuana (weed, oil, or hash by smoking, vaping, or in food) or “synthetic marijuana” (like “K2” or “Spice”)?

• 0
• 1 or more

During the past 12 months, how many days did you use anything else to get high (like illegal drugs, prescription or over-the-counter medications, and things that yo sniff, huff, or vape?

• 0
• 1 or more

During the past 12 months, how many days did you use any tobacco or nicotine products (like cigarettes, e-cigarettes, hookahs, or smokeless tobacco)?

• 0
• 1 or more

During the past two weeks, have you been bothered by little interest or pleasure in doing things?

• No
• Yes

During the past two weeks, have you been bothered by feeling down, depressed, or hopeless?

• No
• Yes

During the past 12 months, have you considered harming or killing yourself?

• No
• Yes

What is your sex?

• Male
• Female
• Prefer not to answer

How many children do you have that are 5 years old and younger?

• 0
• 1
• 2
• 3 or more

Are you pregnant?

• No
• Yes

How many times in the past year have you had 4 or more drinks in a day?

• 0
• 1 or more

How many times have you used a recreational drug or used a prescription medication for non medical reasons?

• 0
• 1 or more

During the past two weeks, have you been bothered by little interest or pleasure in doing things?

• No
• Yes

During the past two weeks, have you been bothered by feeling down, depressed, or hopeless?

• No
• Yes

During the past 12 months, have you considered harming or killing yourself?

• No
• Yes

Can you or are you willing to go to a residential treatment center, or only outpatient?

• Yes
• Only Outpatient

Do you have insurance?

• No
• Yes

Are you parenting and need to take your child into treatment with you?

• No
• Yes

Are you on Medicaid?

• No
• Yes

Do you have the financial means to pay for your treatment?

• No
• Yes

Have you visited the ER or been hospitalized due to the use of drugs or alcohol over the past 30 days?

• No
• Yes