* Depression Scale

** Work/Social

Adjustment

Scale

*** Patient Global

Impression of

Improvement

Medication

Compliance

Patient's Call History:

Follow-Up Report

Patient's ID:

Date:

Fax for:

Fax from:

08/07/00

Healthcare Technology Systems, Inc.

Questions about this fax ? Call 1-800-316-2414

12345

Physician Name

21

N/A

12/09/1999

N/A

9

Baseline Call:

16

Yes

12/28/1999

2

8

Follow Up Call:

6

Yes

01/18/2000

1

4

Follow Up Call:

8

Yes

03/16/2000

2

5

Follow Up Call:

7

Yes

03/17/2000

2

2

Follow Up Call:

4

Yes

03/22/2000

2

2

Follow Up Call:

14

Yes

06/27/2000

2

9

Follow Up Call:

* Depression Scale (Hospital Anxiety and

Depression Scale/Depression Subscale Score)

0-3 Normal Range

4-7 Subclinical

8-10 Mildly Depressed

11-14 Moderately Depressed

15-21 Severely Depressed

** Work and Social Adjustment Scale:

0-5 Not At All Impaired

6-12 Slightly Impared

13-25 Definitely Impaired

26-35 Markedly Impaired

36-40 Very Severely Impaired

*** Patient Global Impression of Improvement

(This scale not asked at Baseline)

1 Very Much Better

2 Much Better

3 A Little Better

4 About the Same

5 A Little Worse

6 Much Worse

7 Very Much Worse

Medication Compliance

This question not asked at Baseline.

Yes = patient answered "yes" to the question "Are

you taking your medication as directed?"

N/A = Not Applicable

This report is an adjunctive tool, not a substitute for clinical diagnosis

Healthcare Technology Systems, Inc. • 7617 Mineral Point Road, Suite 300 • Madison, WI 53717

Phone : (608) 827-2440 • Fax (608) 827-2444

www.healthtechsys.com

© 2000 Healthcare Technology Systems, Inc.