Program Name: __________________________________ Date of Report: ___________
Report Period: from: _______________ to: _____________
| Your Clinic (n = ) |
Regional Norm (n = ) |
|||
|---|---|---|---|---|
| Mean | Range | Mean | Range | |
| 1. Physical health status | ||||
| 2. Healthcare utilization | ||||
| 3. Employment status | ||||
| 4. Support system evaluation | ||||
| 5. Alcohol/drug use | ||||
| 6. Self-help utilization | ||||
| 7. Legal status | ||||
| 8. Family status | ||||
| 9. Mental/emotional status | ||||