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End of Therapy Questionnaires
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Name
*
First
Last
PHQ-9
Over the
last 2 weeks
, how often have you
been bothered by any of the following problems?
1. Little interest or pleasure in doing things
*
Not at all
Several days
More than half the days
Nearly every day
2. Feeling down, depressed, or hopeless
*
Not at all
Several days
More than half the days
Nearly every day
3. Trouble falling or staying asleep, or sleeping too much
*
Not at all
Several days
More than half the days
Nearly every day
4. Feeling tired or having little energy
*
Not at all
Several days
More than half the days
Nearly every day
5. Poor appetite or overeating
*
Not at all
Several days
More than half the days
Nearly every day
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
*
Not at all
Several days
More than half the days
Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television
*
Not at all
Several days
More than half the days
Nearly every day
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
*
Not at all
Several days
More than half the days
Nearly every day
9. Thoughts that you would be better off dead or of hurting yourself in some way
*
Not at all
Several days
More than half the days
Nearly every day
GAD-7
Over the
last 2 weeks
, how often have you been bothered by the following problems?
1. Feeling nervous, anxious or on edge
*
Not at all
Several days
More than half the days
Nearly every day
2. Not being able to stop or control worrying
*
Not at all
Several days
More than half the days
Nearly every day
3. Worrying too much about different things
*
Not at all
Several days
More than half the days
Nearly every day
4. Trouble relaxing
*
Not at all
Several days
More than half the days
Nearly every day
5. Being so restless that it is hard to sit still
*
Not at all
Several days
More than half the days
Nearly every day
6. Becoming easily annoyed or irritable
*
Not at all
Several days
More than half the days
Nearly every day
7. Feeling afraid as if something awful might happen
*
Not at all
Several days
More than half the days
Nearly every day
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
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