Questionnaire

Hello! Please click the button below to complete a short questionnaire. Doing this regularly is one way we can track how therapy is going. Your responses will be emailed directly to Dr Forzisi.

PART 1: Over the last 2 weeks, how often have you been bothered by any of the following problems?
Please select one answer for each question, then submit
1. Little interest or pleasure in doing things *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
2. Feeling down, depressed, or hopeless *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
3. Trouble falling or staying asleep, or sleeping too much *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
4. Feeling tired or having little energy *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
5. Poor appetite or overeating *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
9. Thoughts that you would be better off dead or of hurting yourself in some way *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
PART 2: Over the last 2 weeks, how often have you been bothered by any of the following problems?
Please select one answer for each question, then submit
1. Feeling nervous, anxious or on edge *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
2. Not being able to stop or control worrying *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
3. Worrying too much about different things *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
4. Trouble relaxing *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
5. Being so restless that it is hard to sit still *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
6. Becoming easily annoyed or irritable *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
7. Feeling afraid as if something awful might happen *
0 = Not all, 1 = Several days, 2= More than half the days, 3 = Nearly every day
PART 3: People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity.
Please select a number from 0 to 8 based on the scale provided.
1. WORK - if you are retired or choose not to have a job for reasons unrelated to your problem, please tick N/A (not applicable) *
0 = Not at all; 1; 2 = Slightly; 3; 4 = Definitely; 5; 6 = Markedly; 7; 8 = Very severely, I cannot work
2. HOME MANAGEMENT – Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc *
0 = Not at all; 1; 2 = Slightly; 3; 4 = Definitely; 5; 6 = Markedly; 7; 8 = Very severely, I cannot work
3. SOCIAL LEISURE ACTIVITIES - With other people, e.g. parties, pubs, outings, entertaining etc. *
0 = Not at all; 1; 2 = Slightly; 3; 4 = Definitely; 5; 6 = Markedly; 7; 8 = Very severely, I cannot work
4. PRIVATE LEISURE ACTIVITIES – Done alone, e.g. reading, gardening, sewing, hobbies, walking etc. *
0 = Not at all; 1; 2 = Slightly; 3; 4 = Definitely; 5; 6 = Markedly; 7; 8 = Very severely, I cannot work
5. FAMILY AND RELATIONSHIPS – Form and maintain close relationships with others including the people that I live with *
0 = Not at all; 1; 2 = Slightly; 3; 4 = Definitely; 5; 6 = Markedly; 7; 8 = Very severely, I cannot work