TDDSS Assessment Form

We are very grateful for your help in completing these questionnaires. The information provided will form part of your assessment. There are no right or wrong answers to these questions. We are most interested in your own personal views rather than those of your family or others who may be treating you. We would like you to answer the questions as honestly and as quickly as possible. The responses are confidential. Thank you very much
 

1. What is your name? *

*
*
 

2. What is your date of birth? *

   DD/MM/YYYY 
 
 

3. PHQ-9

Over the last 2 weeks, how often have you been bothered by any of the following problems?
Scoring: 0 - Not at all, 1 - Several days, 2 - More than half the days, 3 - Nearly every day *

0123
1. Little Interest or pleasure in doing things.
2. Feeling down, depressed or hopeless.
3. Trouble falling or staying asleep, or sleeping too much.
4. Feeling tired or having little energy.
5. Poor appetite or overeating.
6. Feeling bad about yourself, or that you are a failure or have let yourself or your family down.
7. Trouble concentrating on things such as reading a newspaper or watching television.
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.
9. Thoughts that you would be better off dead or of hurting yourself in some way.
 

4. GAD-7

Over the last 2 weeks, how often have you been bothered by any of the following problems?
Scoring: 0 - Not at all, 1 - Several days, 2 - More than half the days, 3 - Nearly every day *

0123
1. Feeling Nervous, anxious or on edge.
2. Not being able to stop or control worrying.
3. Worrying too much about different things.
4. Trouble relaxing.
5. Being so restless it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen.
 

5. Social Adjustment

Please rate as follows: 0 = Not at all impaired, 1-2 = Slightly impaired, 3-4 = Definitely impaired, 5-6 = Markedly impaired, 7-8 = Very severely impaired *

012345678
Because of my illness, my ability to go to work is impaired (if you cannot work please score 8).
Because of my illness, my home management is impaired (cleaning, shopping, cooking, child care, paying bills etc.)
Because of my illness, my social & leisure activities are impaired (with other people, e.g. outings, visitors, parties, etc.)
Because of my illness, my private leisure activities are impaired (done alone, e.g. reading, gardening, walking alone, sewing, etc.)
Because of my illness, my ability to form and maintain relationships is impaired.
 

6. Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM)

This section has 34 statements about how you have been OVER THE LAST WEEK. Please read each statement and think how often you felt that way last week. Then tick the box which is closest to it. Scoring: 0 =Not at all, 1 = Only Occasionally, 2 = Sometimes, 3 = Often, 4 = Most or all of the time. *

01234
1. I have felt terribly alone and isolated
2. I have felt tense, anxious or nervous
3. I have felt totally lacking in energy and enthusiasm
4. I have been physically violent to others
5. I have been troubled by aches, pains or other physical problems
6. I have thought of hurting myself
7. Talking to people has felt too much for me
8. Tension and anxiety have prevented me doing important things
9. I have been disturbed by unwanted thoughts and feelings
10. I have felt like crying
11. I have felt panic or terror
12. I have made plans to end my life
13. I have felt overwhelmed by my problems
14. I have had difficulty getting to sleep or staying asleep
15. My problems have been impossible to put to one side
16. I have threatened or intimidated another person
17. I have felt despairing or hopeless
18. I have thought it would be better if I were dead
19. I have felt criticised by other people
20. I have thought I have no friends
21. I have felt unhappy
22. Unwanted images or memories have been distressing me
23. I have been irritable when with other people
24. I have thought I am to blame for my problems and difficulties
25. I have felt humiliated or shamed by other people
26. I have hurt myself physically or taken dangerous risks with my health
 

7. CORE-OM (part two)

Please read each statement and think how often you felt that way last week. Then tick the box which is closest to it. Scoring: 0 =Not at all, 1 = Only Occasionally, 2 = Sometimes, 3 = Often, 4 = Most or all of the time. *

01234
27. I have felt I have someone to turn to for support when needed
28. I have felt OK about myself
29. I have felt able to cope when things go wrong
30. I have been happy with the things I have done
31. I have felt warmth or affection for someone
32. I have been able to do most things I needed to
33. I have felt optimistic about my future
34. I have achieved the things I wanted to
 

8. Why did you choose medicine as a career?