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Confidential patient report

M3 Mental Health and Pain Report

Name: Sample Patient

Birthdate: 01/15/1980

Date of report: 06/09/2026

M3 Scores

M3 Total Score

38 of 108

Moderate

Gateway Risk¹

Positive

Follow up

PEG Pain Score (0–10)

5.7

P1: 6 · P2: 5 · P3: 6

An M3 Total Score of 33 or higher suggests your symptoms may be affecting your life and should be discussed with your clinician.

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 patient means.

Symptom severity scores

Depression

15

of 28

Moderate

Anxiety

9

of 32

Mild

PTSD

6

of 16

Mild

Bipolar

4

of 16

Mild

Functional impairment

Q5I have had thoughts of suicide1 · Rarely

Q24Symptoms interfere with my work or school2 · Sometimes

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 Patient

Birthdate: 01/15/1980

Date of report: 06/09/2026

Your scores over time

M3 Total PEG (pain) Depression Anxiety PTSD Bipolar

Top symptoms by category

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

Depression

Q1I feel sad, down in the dumps or unhappy3

Q3Nothing seems to give me much pleasure3

Anxiety

Q8I feel tense, anxious or can't sit still2

Q9I feel worried or fearful2

PTSD

Q14I am jumpy or feel startled easily2

Q16I feel dull, numb, or detached2

Bipolar

Q21I have felt unusually irritable or angry2

Q20I have more energy than usual1

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 Patient

Birthdate: 01/15/1980

Date of report: 06/09/2026

Over the last two weeks or more, have you noticed the following?

Depression symptomsMajor Depression

1I feel sad, down in the dumps or unhappy3

2I can't concentrate or focus2

3Nothing seems to give me much pleasure3

4I feel tired; have no energy3

5I have had thoughts of suicide1

6aI have difficulty sleeping2

6bI sleep too much0

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 still2

9I feel worried or fearful2

10I have attacks of anxiety or panic1

11I worry about dying or losing control0

12I am nervous or shaky in social situations1

PTSD symptomsPost-Traumatic Stress Disorder

13I have nightmares or flashbacks1

14I am jumpy or feel startled easily2

15I avoid places that remind of a bad experience1

16I feel dull, numb, or detached2

Other anxiety symptomsObsessive-Compulsive Disorder

17I can't get certain thoughts out of my mind2

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 angry2

22I have felt unusually excited, revved up or high0

23I have needed less sleep than usual1

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

24…interferes with my work or school2

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 (Q8–12, 17–19)

PTSD (Q13–16)

Bipolar (Q20–23)

Functional impairment (Q5, Q24–27)

PEG pain scale (0–10)

6P1. Pain on average in the past week

5P2. Pain interfered with enjoyment of life

6P3. Pain interfered with general activity

PEG average: 5.7

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