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Confidential patient report

M3 Mental Health and Pain Report

Name: Sample Report

Birthdate: 01/15/1980

Date of report: 08/17/2026

Three check-ins, twelve weeks apart. The M3 total was 45 on 3/2/2026 — about 36% above the line of 33 — then 37 on 5/25/2026, about 12% above, and 29 today, below the line. Pain eased from 6 to 3. This page shows today’s check-in; page 2 shows all three.

M3 Scores

M3 Total Score

29 of 108

Mild

Mood — depression, anxiety, PTSD, bipolar.

Gateway Risk¹

Negative

No flag

Reviewed one by one — never counted into a total.

DVPRS Pain (0–10)

3

Mild

Pain — and its effect on sleep, mood, activity.

An M3 Total Score of 33 or higher suggests your symptoms may be affecting your life and should be discussed with your clinician. Today’s total of 29 is below that line; it was 37 twelve weeks ago and 45 twenty-four weeks ago.

Symptom severity ranges: each category below is rated Low, Mild, Moderate, or Severe based on its score. The Functional Impairment Questions (Questions 5 and 24 through 27) address functional status, substance use, and thoughts of suicide. Positive answers to these questions should be followed by additional questions to understand what the person means.

Symptom severity scores

Depression

10

of 28

Mild

Anxiety

13

of 48

Mild

PTSD

5

of 16

Mild

Bipolar

3

of 16

Low

Functional impairment

Q5I have had thoughts of suicide0 · Not at all

Q24Symptoms interfere with my work or school1 · Rarely

Q25Symptoms affect my relationships with friends or family1 · Rarely

Q26Symptoms have led to my using alcohol to get by1 · Rarely

Q27Symptoms have led to my using other substances0 · Not at all

¹ Gateway: the gateway questions (thoughts of suicide — Q5; functional impairment and substance use — Q24–Q27) are reviewed individually. A positive response on any gateway question warrants clinical follow-up regardless of the total score.

This report is a screening aid, not a diagnosis. Please review the results with your clinician. · Page 1 of 3

If you are having thoughts of suicide or are in crisis, call or text 988 (Suicide & Crisis Lifeline) any time, day or night, or go to the nearest emergency room.

M3 Mental Health | m3mentalhealth.org

Confidential patient report

M3 Mental Health and Pain Report

Name: Sample Report

Birthdate: 01/15/1980

Date of report: 08/17/2026

Your scores over time

M3 Total Depression Anxiety PTSD Bipolar

Three check-ins, twelve weeks apart

Date	M3 total	Against the line of 33	Depression · Anxiety · PTSD · Bipolar	DVPRS pain right now
3/2/2026	45 Moderate	about 36% above 33	15 · 20 · 8 · 4	6 Moderate
5/25/2026 (+12 weeks)	37 Moderate	about 12% above 33	13 · 16 · 6 · 4	5 Moderate
8/17/2026 (+24 weeks)	29 Mild	below 33	10 · 13 · 5 · 3	3 Mild

Pain has its own 0–10 scale, so it is listed here rather than drawn on the chart. Green 0–4 mild · yellow 5–6 moderate · red 7–10 severe.

Top symptoms by category

0Not at all 1Rarely 2Sometimes 3Often 4Most of the time

Depression

Q1I feel sad, down in the dumps or unhappy2

Q2I can't concentrate or focus2

Anxiety

Q10I have attacks of anxiety or panic2

Q8I feel tense, anxious or can't sit still1

PTSD

Q13I have nightmares or flashbacks2

Q14I am jumpy or feel startled easily1

Bipolar

Q20I have more energy than usual1

Q21I have felt unusually irritable or angry1

This report is a screening aid, not a diagnosis. Please review the results with your clinician. · Page 2 of 3

M3 Mental Health | m3mentalhealth.org

Confidential patient report

Answers to the questions

Name: Sample Report

Birthdate: 01/15/1980

Date of report: 08/17/2026

Over the last two weeks or more, have you noticed the following? (Today’s check-in, 8/17/2026.)

Depression symptomsMajor Depression

1I feel sad, down in the dumps or unhappy2

2I can't concentrate or focus2

3Nothing seems to give me much pleasure2

4I feel tired; have no energy1

5I have had thoughts of suicide0

6aI have difficulty sleeping2

6bI sleep too much1

7aI have lost some appetite1

7bI am eating more0

Anxiety symptomsGeneralized Anxiety (Q8–9) · Panic Disorder (Q10–11) · Social Anxiety (Q12)

8I feel tense, anxious or can't sit still1

9I feel worried or fearful1

10I have attacks of anxiety or panic2

11I worry about dying or losing control1

12I am nervous or shaky in social situations1

PTSD symptomsPost-Traumatic Stress Disorder

13I have nightmares or flashbacks2

14I am jumpy or feel startled easily1

15I avoid places that remind of a bad experience1

16I feel dull, numb, or detached1

Other anxiety symptomsObsessive-Compulsive Disorder

17I can't get certain thoughts out of my mind1

18I must repeat certain acts or rituals0

19I feel the need to check and recheck things1

Bipolar symptomsBipolar Disorder (unstable mood)

20I have more energy than usual1

21I have felt unusually irritable or angry1

22I have felt unusually excited, revved up or high1

23I have needed less sleep than usual0

Functional impairmentwhether any of the above symptoms… (Q5 also reviewed here)

24…interferes with my work or school1

25…affects my relationships with friends or family1

26…has led to my using alcohol to get by1

27…has led to my using other substances0

Legend — answer scale

0Not at all

1Rarely

2Sometimes

3Often

4Most of the time

Legend — categories

Depression (Q1–7)

Anxiety (Q8–19, including the PTSD items)

PTSD (Q13–16)

Bipolar (Q20–23)

Functional impairment (Q5, Q24–27)

DVPRS pain scale (0–10)

3Pain right now. “Sometimes distracts me”

3Activity. Interfered with usual activity, past 24 hours

2Sleep. Interfered with sleep, past 24 hours

3Mood. Affected mood, past 24 hours

3Stress. Contributed to stress, past 24 hours

The pain score is the first number: 3 Mild (it was 6, then 5). The four past-24-hour answers are shown one by one and never averaged. Bands: 0 no pain · green 1–4 mild · yellow 5–6 moderate · red 7–10 severe.

Other symptoms to ask about

Depression: feelings of worthlessness or excessive guilt; psychomotor agitation or retardation; aches and pains; recurrent thoughts of death or suicide

GAD: muscle tension; aches and pains

Panic Disorder: palpitations, tachycardia, dyspnea, choking feeling, chest pain or discomfort, dizziness, light-headedness; sweating, hot or cold flashes; trembling, paresthesias; persistent fear of future attacks; a change in behavior related to the attacks; feeling of unreality (derealization), feeling detached from oneself, fear of losing control or of going crazy. Consider Agoraphobia: anxiety or panic associated with “unsafe” locations