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00691862 Health Assured Questionaire
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00691862 Health Assured Questionaire
00691862 – Health Assured Client Questionnaire
Complete the whole Form Before You Start Your Session
Client ID
Which Counsellor
Victoria
Questionnaire (part 1) PHQ-9
Q1 – Have you found little pleasure or interest in doing things?
*
Never
Few Days
Most Days
Almost Every Day
Q2 – Have you found yourself feeling down, depressed or hopeless?
*
Never
Few Days
Most Days
Almost Every Day
Q3 -Have you had trouble falling or staying asleep, or sleeping too much?
*
Never
Few Days
Most Days
Almost Every Day
Q4 -How often have you been bothered by feeling tired or having little energy?
*
Never
Few Days
Most Days
Almost Every Day
Q5 – How often have you been bothered by poor appetite or overeating?
*
Never
Few Days
Most Days
Almost Every Day
Q6 -How often have you been bothered by feeling bad about yourself, or that you are a failure, or have let yourself or your family down?
*
Never
Few Days
Most Days
Almost Every Day
Q7 – How often have you been bothered by trouble concentrating on things, such as reading the newspaper or watching television?
*
Never
Few Days
Most Days
Almost Every Day
Q8 – How often have you been bothered by 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?
*
Never
Few Days
Most Days
Almost Every Day
Q9 – Thoughts that you would be better off dead, or of hurting yourself in some way?
*
Never
Few Days
Most Days
Almost Every Day
Questionnaire (part 2) GAD-7
Q1 – How often have you been bothered about feeling nervous, anxious or on edge?
*
Never
Few Days
Most Days
Almost Every Day
Q2 – How often have you been bothered by not being able to stop or control worrying?
*
Never
Few Days
Most Days
Almost Every Day
Q3 – How often have you been bothered by worrying too much about different things?
*
Never
Few Days
Most Days
Almost Every Day
Q4 – How often have you been bothered by having trouble relaxing?
*
Never
Few Days
Most Days
Almost Every Day
Q5 – How often have you been bothered by being so restless that it is hard to sit still?
*
Never
Few Days
Most Days
Almost Every Day
Q6 – How often have you been bothered by becoming easily annoyed or irritable?
*
Never
Few Days
Most Days
Almost Every Day
Q7 – How often have you been bothered by feeling afraid as if something awful might happen?
*
Never
Few Days
Most Days
Almost Every Day
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