Mental and Physical Health Score To 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 headaches 0 1 2 3 4 2. I feel nervous inside 0 1 2 3 4 3. I always have words or thoughts I cannot stop thinking 0 1 2 3 4 4. I have feelings of fainting or dizziness 0 1 2 3 4 5. I have lost sexual interest 0 1 2 3 4 6. I feel antagonistic to others 0 1 2 3 4 7. I feel my thoughts are controlled by someone else 0 1 2 3 4 8. I feel that others are to blame for most of my problems 0 1 2 3 4 9. I forget things a lot of the time 0 1 2 3 4 10. I get worried about being untidy or careless 0 1 2 3 4 1 out of 9 11. I easily get upset or irritated 0 1 2 3 4 12. I get a pain in my heart and chest area 0 1 2 3 4 13. I am afraid of open spaces or going out 0 1 2 3 4 14. I lack energy and feel sluggish 0 1 2 3 4 15. I have thoughts of killing myself 0 1 2 3 4 16. I hear voices that others cannot hear 0 1 2 3 4 17. I feel unsteady or get tremblings 0 1 2 3 4 18. I feel that most people are unreliable 0 1 2 3 4 19. I have a poor appetite 0 1 2 3 4 20. I find it easy to cry 0 1 2 3 4 2 out of 9 21. I feel shy and uneasy with people of the opposite sex 0 1 2 3 4 22. I have feelings of being trapped 0 1 2 3 4 23. I have sudden fears without any reason 0 1 2 3 4 24. I get uncontrolled outbursts of anger 0 1 2 3 4 25. I am afraid to go out alone 0 1 2 3 4 26. I blame myself for everything 0 1 2 3 4 27. I get pains in my lower back area 0 1 2 3 4 28. I find it difficult to get things done 0 1 2 3 4 29. I feel lonely 0 1 2 3 4 30. I feel low 0 1 2 3 4 3 out of 9 31. I worry too much about things 0 1 2 3 4 32. I have no interest in anything 0 1 2 3 4 33. I have feelings of fear and anxiety 0 1 2 3 4 34. I get easily hurt 0 1 2 3 4 35. I feel that others can read my mind 0 1 2 3 4 36. I feel others don’t understand or care about me 0 1 2 3 4 37. I feel others are unfriendly and disapprove of me 0 1 2 3 4 38. I have to do things very deliberately to make sure what I am doing is correct/right 0 1 2 3 4 39. I get a racing pounding heart feeling 0 1 2 3 4 40. I get feelings of nausea or upset stomach 0 1 2 3 4 4 out of 9 41. I get feelings of being inferior 0 1 2 3 4 42. I get feelings of pain or tenderness in my muscles 0 1 2 3 4 43. I feels others are watching me or talking about me 0 1 2 3 4 44. I find it hard to go to sleep 0 1 2 3 4 45. I need to do something over and over again to make sure I did it properly before 0 1 2 3 4 46. I find it difficult to make decisions 0 1 2 3 4 47. I am frightened to go on a train, bus, underground 0 1 2 3 4 48. I find it difficult to breathe 0 1 2 3 4 49. I feel hot/ cold waves running through my body 0 1 2 3 4 50. I avoid certain things, places and situations because they are frightening 0 1 2 3 4 5 out of 9 51. I have a feeling that my mind has gone blank 0 1 2 3 4 52. I feel numbness, pins/needles in some parts of my body 0 1 2 3 4 53. I feel a lump in my throat 0 1 2 3 4 54. I have feelings of hopelessness about my future 0 1 2 3 4 55. I find it hard to concentrate 0 1 2 3 4 56. I feel weak in different parts of my body 0 1 2 3 4 57. I feel tense or overexcited 0 1 2 3 4 58. I feel heaviness in my arms or legs 0 1 2 3 4 59. I think about death and what it would be like to die 0 1 2 3 4 60. I feel I am overeating 0 1 2 3 4 6 out of 9 61. I feel uneasy when others look at me and talk about me 0 1 2 3 4 62. I think thoughts that are not really me 0 1 2 3 4 63. I have impulsive feelings to hurt others 0 1 2 3 4 64. I wake up very early in the morning 0 1 2 3 4 65. I have certain acts that I must repeat many times in a certain pattern e.g. touch or clean things over and over again 0 1 2 3 4 66. I have worried or disturbed sleep 0 1 2 3 4 67. I have impulses to break or smash things 0 1 2 3 4 68. I have thoughts/ ideas that others don’t have 0 1 2 3 4 69. I feel preoccupied with myself when I am with others 0 1 2 3 4 70. I feel uneasy in crowds – shop/cinema/sport 0 1 2 3 4 7 out of 9 71. I feel all is hard to do – physically tired and exhausted 0 1 2 3 4 72. I feel anxiety or panic attacks 0 1 2 3 4 73. I don’t feel good when I go out of for a meal/drink 0 1 2 3 4 74. I often find myself in heated discussions 0 1 2 3 4 75. I feel nervous when I am alone 0 1 2 3 4 76. I feel others do not appreciate what I am doing 0 1 2 3 4 77. I feel alone even when in company 0 1 2 3 4 78. I feel restless and unable to sit still 0 1 2 3 4 79. I feel worthless 0 1 2 3 4 80. Familiar things feel strange and unreal 0 1 2 3 4 8 out of 9 81. I scream or throw things 0 1 2 3 4 82. I am afraid I may faint when out with others 0 1 2 3 4 83. I feel others would use me if they could 0 1 2 3 4 84. I feel disturbing sexual thoughts 0 1 2 3 4 85. I feel I should be punished for my sins 0 1 2 3 4 86. I have a compulsive need to get things done 0 1 2 3 4 87. I feel something is seriously physically wrong with me 0 1 2 3 4 88. I feel I am never really close to anyone 0 1 2 3 4 89. I have feelings of guilt 0 1 2 3 4 90. I think there is something wrong in my mind 0 1 2 3 4 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! Time's up
