Mental and Physical Health ScoreTo complete the questionnaire, choose the most appropriate score between 0-4 for how you are feeling now. For example:0: If you don't feel this at all1: If you feel it a little2: If you feel it from time to time3: If you feel it quite a lot4: If you feel it most of the time Please fill in your contact details and proceed to Part Two by pressing Next. Full Name Your Email Mobile Employment 1. I get headaches01234 2. I feel nervous inside01234 3. I always have words or thoughts I cannot stop thinking01234 4. I have feelings of fainting or dizziness01234 5. I have lost sexual interest01234 6. I feel antagonistic to others01234 7. I feel my thoughts are controlled by someone else01234 8. I feel that others are to blame for most of my problems01234 9. I forget things a lot of the time01234 10. I get worried about being untidy or careless01234 1 out of 9 11. I easily get upset or irritated01234 12. I get a pain in my heart and chest area01234 13. I am afraid of open spaces or going out01234 14. I lack energy and feel sluggish01234 15. I have thoughts of killing myself01234 16. I hear voices that others cannot hear01234 17. I feel unsteady or get tremblings01234 18. I feel that most people are unreliable01234 19. I have a poor appetite01234 20. I find it easy to cry01234 2 out of 9 21. I feel shy and uneasy with people of the opposite sex01234 22. I have feelings of being trapped01234 23. I have sudden fears without any reason01234 24. I get uncontrolled outbursts of anger01234 25. I am afraid to go out alone01234 26. I blame myself for everything01234 27. I get pains in my lower back area01234 28. I find it difficult to get things done01234 29. I feel lonely01234 30. I feel low01234 3 out of 9 31. I worry too much about things01234 32. I have no interest in anything01234 33. I have feelings of fear and anxiety01234 34. I get easily hurt01234 35. I feel that others can read my mind01234 36. I feel others don’t understand or care about me01234 37. I feel others are unfriendly and disapprove of me01234 38. I have to do things very deliberately to make sure what I am doing is correct/right01234 39. I get a racing pounding heart feeling01234 40. I get feelings of nausea or upset stomach01234 4 out of 9 41. I get feelings of being inferior01234 42. I get feelings of pain or tenderness in my muscles01234 43. I feels others are watching me or talking about me01234 44. I find it hard to go to sleep01234 45. I need to do something over and over again to make sure I did it properly before01234 46. I find it difficult to make decisions01234 47. I am frightened to go on a train, bus, underground01234 48. I find it difficult to breathe01234 49. I feel hot/ cold waves running through my body01234 50. I avoid certain things, places and situations because they are frightening01234 5 out of 9 51. I have a feeling that my mind has gone blank01234 52. I feel numbness, pins/needles in some parts of my body01234 53. I feel a lump in my throat01234 54. I have feelings of hopelessness about my future01234 55. I find it hard to concentrate01234 56. I feel weak in different parts of my body01234 57. I feel tense or overexcited01234 58. I feel heaviness in my arms or legs01234 59. I think about death and what it would be like to die01234 60. I feel I am overeating01234 6 out of 9 61. I feel uneasy when others look at me and talk about me01234 62. I think thoughts that are not really me01234 63. I have impulsive feelings to hurt others01234 64. I wake up very early in the morning01234 65. I have certain acts that I must repeat many times in a certain pattern e.g. touch or clean things over and over again01234 66. I have worried or disturbed sleep01234 67. I have impulses to break or smash things01234 68. I have thoughts/ ideas that others don’t have01234 69. I feel preoccupied with myself when I am with others01234 70. I feel uneasy in crowds – shop/cinema/sport01234 7 out of 9 71. I feel all is hard to do – physically tired and exhausted01234 72. I feel anxiety or panic attacks01234 73. I don’t feel good when I go out of for a meal/drink01234 74. I often find myself in heated discussions01234 75. I feel nervous when I am alone01234 76. I feel others do not appreciate what I am doing01234 77. I feel alone even when in company01234 78. I feel restless and unable to sit still01234 79. I feel worthless01234 80. Familiar things feel strange and unreal01234 8 out of 9 81. I scream or throw things01234 82. I am afraid I may faint when out with others01234 83. I feel others would use me if they could01234 84. I feel disturbing sexual thoughts01234 85. I feel I should be punished for my sins01234 86. I have a compulsive need to get things done01234 87. I feel something is seriously physically wrong with me01234 88. I feel I am never really close to anyone01234 89. I have feelings of guilt01234 90. I think there is something wrong in my mind01234I accept the Privacy Policy of this questionnaire 9 out of 9 [caption id="attachment_4566" align="alignnone" width="957"] Thank you for completing your personal score, it is time well spent. Your confidential answers will help me design your therapy needs.[/caption]I look forward to working with you.DianaThis completes the questionnaire, please press Submit to close the page. Time is Up!
