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 all
1: If you feel it a little
2: If you feel it from time to time
3: If you feel it quite a lot
4: 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

I get headaches

0 1 2 3 4

I feel nervous inside

0 1 2 3 4

I always have words or thoughts I cannot stop thinking

0 1 2 3 4

I have feelings of fainting or dizziness

0 1 2 3 4

I have lost sexual interest

0 1 2 3 4

I feel antagonistic to others

0 1 2 3 4

I feel my thoughts are controlled by someone else

0 1 2 3 4

I feel that others are to blame for most of my problems

0 1 2 3 4

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

Diana Luke HypnoTherapist 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.

Diana

This completes the questionnaire, please press Submit to close the page.

Time is Up!

Time's up

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

0: If you don't feel this at all
1: If you feel it a little
2: If you feel it from time to time
3: If you feel it quite a lot
4: If you feel it most of the time