Demographics |
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Today's Date : |
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Client code: |
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Date of birth : |
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Gender: |
Male Female |
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Your psychologist : |
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Questionnaire |
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1 |
I get along well with others : |
Never Rarely Sometimes Frequently Almost always |
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2 |
I tire quickly : |
Never Rarely Sometimes Frequently Almost always |
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3 |
I feel no interest in things : |
Never Rarely Sometimes Frequently Almost always |
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4 |
I feel stressed at work/school : |
Never Rarely Sometimes Frequently Almost always |
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5 |
I blame myself for things : |
Never Rarely Sometimes Frequently Almost always |
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6 |
I feel irritated : |
Never Rarely Sometimes Frequently Almost always |
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7 |
I feel unhappy in my marriage or significant relationship : |
Never Rarely Sometimes Frequently Almost always |
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8 |
I have thoughts of ending my life : |
Never Rarely Sometimes Frequently Almost always |
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9 |
I feel weak : |
Never Rarely Sometimes Frequently Almost always |
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10 |
I feel fearful : |
Never Rarely Sometimes Frequently Almost always |
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11 |
After heavy drinking, I need a drink the next morning to get going. (If you do not drink, mark "never" : |
Never Rarely Sometimes Frequently Almost always |
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12 |
I find my work/school satisfying : |
Never Rarely Sometimes Frequently Almost always |
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13 |
I am a happy person : |
Never Rarely Sometimes Frequently Almost always |
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14 |
I work/study too much : |
Never Rarely Sometimes Frequently Almost always |
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15 |
I feel worthless : |
Never Rarely Sometimes Frequently Almost always |
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16 |
I am concerned about family troubles : |
Never Rarely Sometimes Frequently Almost always |
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17 |
I have an unfulfilling sex life : |
Never Rarely Sometimes Frequently Almost always |
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18 |
I feel lonely : |
Never Rarely Sometimes Frequently Almost always |
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19 |
I have frequent arguments : |
Never Rarely Sometimes Frequently Almost always |
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20 |
I feel loved and wanted : |
Never Rarely Sometimes Frequently Almost always |
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21 |
I enjoy my spare time : |
Never Rarely Sometimes Frequently Almost always |
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22 |
I have difficulty concentrating : |
Never Rarely Sometimes Frequently Almost always |
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23 |
I feel hopeless about the future : |
Never Rarely Sometimes Frequently Almost always |
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24 |
I like myself : |
Never Rarely Sometimes Frequently Almost always |
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25 |
Disturbing thoughts come into my mind that I cannot get rid of : |
Never Rarely Sometimes Frequently Almost always |
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26 |
I feel annoyed by people who criticise my drinking (or drug use) : |
Never Rarely Sometimes Frequently Almost always |
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27 |
I have an upset stomach : |
Never Rarely Sometimes Frequently Almost always |
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28 |
I am not working/studying as well as I used to : |
Never Rarely Sometimes Frequently Almost always |
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29 |
My heart pounds too much : |
Never Rarely Sometimes Frequently Almost always |
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30 |
I have trouble getting along with friends and close acquaintances : |
Never Rarely Sometimes Frequently Almost always |
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31 |
I am satisfied with my life : |
Never Rarely Sometimes Frequently Almost always |
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32 |
I have trouble at work/school because of drinking or drug use (If not applicable, mark "never") : |
Never Rarely Sometimes Frequently Almost always |
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33 |
I feel something bad is going to happen : |
Never Rarely Sometimes Frequently Almost always |
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34 |
I have sore muscles : |
Never Rarely Sometimes Frequently Almost always |
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35 |
I feel afraid of open spaces, of driving, or being on buses, subways or so forth : |
Never Rarely Sometimes Frequently Almost always |
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36 |
I feel nervous : |
Never Rarely Sometimes Frequently Almost always |
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37 |
I feel my love relationships are full and complete : |
Never Rarely Sometimes Frequently Almost always |
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38 |
I feel that I am not doing well at work/school : |
Never Rarely Sometimes Frequently Almost always |
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39 |
I have too many disagreements at work/school : |
Never Rarely Sometimes Frequently Almost always |
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40 |
I feel something is wrong with my mind : |
Never Rarely Sometimes Frequently Almost always |
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41 |
I have trouble falling asleep or staying asleep : |
Never Rarely Sometimes Frequently Almost always |
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42 |
I feel blue : |
Never Rarely Sometimes Frequently Almost always |
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43 |
I am satisfied with my relationships with others : |
Never Rarely Sometimes Frequently Almost always |
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44 |
I feel angry enough at work/school to do something I might regret : |
Never Rarely Sometimes Frequently Almost always |
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45 |
I have headaches : |
Never Rarely Sometimes Frequently Almost always |
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Thank you so much for taking the time to complete this form. |
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