Mood and Wellbeing Questionnaires

Initials and Date of Birth(Required)
MM slash DD slash YYYY

Generalised Anxiety Disorder (GAD-7)

Measures anxiety

Over the last 2 weeks, how often have you been bothered by the following problems?

0 - Not at all, 1 - Several days, 2 - Over half the days, 3 - Nearly every day

GAD 1.Feeling nervous, anxious or on edge(Required)
GAD 2.Not being able to stop or control worrying(Required)
GAD 3.Worrying too much about different things(Required)
GAD 4.Trouble relaxing(Required)
GAD 5.Being so restless that it is hard to sit still(Required)
GAD 6.Becoming easily annoyed or irritable(Required)
GAD 7.Feeling afraid as if something awful might(Required)
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Patient Health Questionnair (PHQ-9)

Measures low mood

Over the last 2 weeks, how often have you been bothered by the following problems?

0 - Not at all, 1 - Several days, 2 - Over half the days, 3 - Nearly every day

PHQ 1- Little interest or pleasure in doing things(Required)
PHQ 2- Feeling down, depressed, or hopeless(Required)
PHQ 3- Trouble falling/staying asleep, sleeping too much(Required)
PHQ 4- Feeling tired or having little energy(Required)
PHQ 5- Poor appetite or overeating(Required)
PHQ 6- Feeling bad about yourself or that you are a failure or have let yourself or your family down(Required)
PHQ 7- Trouble concentrating on things, such as reading the newspaper or watching television.(Required)
PHQ 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.(Required)
PHQ 9- Thoughts that you would be better off dead or of hurting yourself in some way.(Required)
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CORE - 10

Wellbeing Measure

Over the last 2 weeks, how often have you been bothered by the following problems?

0 - Not at all, 1 - Only ocasionally, 2 - Sometimes, 3- Often, 4- Most or all the time

CORE 1- I have felt tense, anxious or nervous(Required)
CORE 2- Talking to people has felt too much for me(Required)
CORE 3- I have felt panic or terror(Required)
CORE 4- I made plans to end my life(Required)
CORE 5- I have had difficulty getting to sleep or staying asleep(Required)
CORE 6- I have felt despairing or hopeless(Required)
CORE 7- I have felt unhappy(Required)
CORE 8- Unwanted images or memories have been distressing me(Required)
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Importat Next 2 Question Change

Over the last 2 weeks, how often have you been bothered by the following problems?

4 - Not at all, 3 - Only ocasionally, 2 - Sometimes, 1- Often, 0 - Most or all the time

CORE 9- I have felt I have someone to turn to for support when needed(Required)
CORE 10- I have felt able to cope when things go wrong(Required)
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Agree Associated Therapist(Required)
Terms & Conditions(Required)