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Home Our Services Mental Health Services What is Steps to Wellness all about? Clinical Questionnaire

Clinical Questionnaire

As part of your intervention with our Steps to Wellness service, we use clinical questionnaires to ensure we best understand how we can help you, and to monitor your symptoms whilst you are in the service.

This form is to collect the 2 main questionnaires we use: The PHQ-9 and the GAD-7. The former explores your symptoms of low mood and depression, the latter focuses on anxiety symptoms.

We also need to ask some identifying questions so that we can ensure your practitioner receives your responses correctly. This data is stored securely and is not shared with any other organisations – it is only used to identify you as the correct service user for your responses.

Name*
First Last
Date
MM slash DD slash YYYY
Name of therapist
Name of Group (if completing as part of a Group Session)
GAD-7: On a scale of 0 (Not at all) to 3 (Nearly every day), over the last 2 weeks, how often have you been bothered by any of the following problems?*
Feeling nervous, anxious or on edge
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
Not being able to stop or control worrying*
Not being able to stop or control worrying
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
Worrying too much about different things*
Worrying too much about different things
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
Trouble relaxing*
Trouble relaxing
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
Being so restless that it is hard to sit still*
Being so restless that it is hard to sit still
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
Becoming easily annoyed or irritable*
Becoming easily annoyed or irritable
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
Feeling afraid as if something awful might happen*
Feeling afraid as if something awful might happen
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
PHQ-9: On a scale of 0 (Not at all) to 3 (Nearly every day), over the last 2 weeks, how often have you been bothered by any of the following problems?*
Little interest or pleasure in doing things
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
Feeling down, depressed, or hopeless*
Feeling down, depressed, or hopeless
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
Trouble falling or staying asleep, or sleeping too much*
Trouble falling or staying asleep, or sleeping too much
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
Feeling tired or having little energy*
Feeling tired or having little energy
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
Poor appetite or overeating*
Poor appetite or overeating
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
Feeling bad about yourself — or that you are a failure or have let yourself or your family down*
Feeling bad about yourself — or that you are a failure or have let yourself or your family down
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television*
Trouble concentrating on things, such as reading the newspaper or watching television
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
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*
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
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way*
Thoughts that you would be better off dead or of hurting yourself in some way
- 0. Not at all
- 1. Several days
- 2. More than half the days
- 3. Nearly every day
I have been thinking of ways to harm myself
- Yes
- No
I have plans to act on these thoughts
- Yes
- No
I feel safe from harm from others
- Yes
- No
Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.
By submitting this form you confirm that the information you have provided is accurate.

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Southern Health and Social Care Trust

Southern College of Nursing, Craigavon Area Hospital, 68 Lurgan Road, Portadown, BT63 5QQ

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028 3833 4444

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028 3083 5000

South Tyrone

028 8772 2821

Lurgan Hospital

028 3832 3262

St Luke's Hospital

028 3752 2381

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