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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.

  • MM slash DD slash YYYY
  • Feeling nervous, anxious or on edge
  • Not being able to stop or control worrying
  • Worrying too much about different things
  • Trouble relaxing
  • Being so restless that it is hard to sit still
  • Becoming easily annoyed or irritable
  • Feeling afraid as if something awful might happen
  • Little interest or pleasure in doing things
  • Feeling down, depressed, or hopeless
  • Trouble falling or staying asleep, or sleeping too much
  • Feeling tired or having little energy
  • Poor appetite or overeating
  • Feeling bad about yourself — or that you are a failure or have let yourself or your family down
  • Trouble concentrating on things, such as reading the newspaper or watching television
  • 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
  • Thoughts that you would be better off dead or of hurting yourself in some way
  • 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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