Mental Health Questionnaires Krippa Family Psychological & Wellness Services

Krippa Family Psychological & Wellness Services

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Mental Health Questionnaires
GAD-7 Anxiety

Choose one answer per question. Add up the column values to calculate your total score.

Over the last two weeks, how often have you been bothered by the following concerns?

Rows	Not at all Score 0 points	Several days Score 1 point	More than half the days Score 2 points	Most days Score 3 points
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 bad might happen?

Total Score: add up the values for each column and total. (column a + column b + column c + column d = total score)*
Not difficult at all.Somewhat difficult.Very difficult.Extremely difficult.
Source: Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD-PHQ). The PHQ was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues. For research information, contact Dr.
Spitzer at ris8@columbia.edu. PRIME-MD® is a trademark of Pfizer Inc. Copyright© 1999 Pfizer Inc. All rights reserved. Reproduced with permission
Beck Depression Inventory

Answer each question and then add up the point values at the end.

Question 1

Rows	Choose One
0 points: I do not feel sad
1 point: I feel sad
2 points: I am sad all the time and I can't snap out of it.
3 points: I am so sad and unhappy that I cannot stand it

Question 2

Rows	Choose One
0 points: I am not particularly discouraged about the future.
1 point: I feel discouraged about the future.
2 points: I feel I have nothing to look forward to.
3 points: I feel the future is hopeless and things cannot improve.

Question 3

Rows	Choose One
0 points: I do not feel like a failure.
1 point: I feel I have failed more than the average person.
2 points: As I look back on my life, all I can see is a lot of failures.
3 points: I feel I am a complete failure as a person.

Question 4

Rows	Choose One
0 points: I get as much satisfaction out of things as I used to.
1 point: I don't enjoy things the way I used to.
2 points: I don't get real satisfaction out of anything anymore.
3 points: I am dissatisfied or bored with everything.

Question 5

Rows	Choose One
0 points: I don't particularly feel guilty.
1 point: I feel guilty a good part of the time.
2 points: I feel quite guilty most of the time.
3 points: I feel guilty all of the time.

Question 6

Rows	Choose One
0 points: I don't feel I am being punished.
1 point: I feel I may be punished.
2 points: I expect to be punished.
3 points: I feel I am being punished.

Question 7

Rows	Choose One
0 points: I don't feel disappointed in myself.
1 point: I am disappointed in myself.
2 points: I am disgusted with myself.
3 points: I hate myself.

Question 8

Rows	Choose One
0 points: I don't feel I am any worse than anybody else.
1 point: I am critical of myself for my weaknesses or mistakes.
2 points: I blame myself all the time for my faults.
3 points: I blame myself for everything bad that happens.

Question 9

Rows	Choose One
0 points: I don't have any thoughts of killing myself.
1 point: I have thoughts of killing myself, but I would not carry them out.
2 points: I would like to kill myself.
3 points: I would kill myself if I had the chance.

Question 10

Rows	Choose One
0 points: I don't cry any more than usual.
1 point: I cry more now than I used to.
2 points: I cry all the time now.
3 points: I used to be able to cry, but now I can't even cry though I want to.

Question 11

Rows	Choose One
0 points: I am not more irritated by things than I ever was.
1 point: I am slightly more irritated now than usual.
2 points: I am quite annoyed or irritated a good deal of the time.
3 points: I feel irritated all the time.

Question 12

Rows	Choose One
0 points: I have not lost interest in other people.
1 point: I am less interested in other people than I used to be.
2 points: I have lost most of my interest in other people.
3 points: I have lost all of my interest in other people.

Question 13

Rows	Choose One
0 points: I make decisions about as well as I ever could.
1 point: I put off making decisions more than I used to.
2 points: I have greater difficulty in making decisions more than I used to.
3 points: I can't make decisions at all anymore.

Question 14

Rows	Choose One
0 points: I don't feel that I look any worse than I used to.
1 point: I am worried that I am looking old or unattractive.
2 points: I feel there are permanent changes in my appearance that make me look unattractive.
3 points: I believe that I look ugly.

Question 15

Rows	Choose One
0 points: I can work out about as well as before.
1 point: It takes extra effort to get started at doing something.
2 points: I have to push myself very hard to do anything.
3 points: I can't do any work at all.

Question 16

Rows	Choose One
0 points: I can sleep as well as usual.
1 point: I don't sleep as well as I used to.
2 points: I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.
3 points: I wake up several hours earlier than I used to and cannot get back to sleep.

Question 17

Rows	Choose One
0 points: I don't get more tired than usual.
1 point: I get tired more easily than I used to.
2 points: I get tired from doing almost anything.
3 points: I am too tired to do anything.

Question 18

Rows	Choose One
0 points: My appetite is no worse than usual.
1 point: My appetite is not as good as it used to be.
2 points: My appetite is much worse now.
3 points: I have no appetite at all anymore.

Question 19

Rows	Choose One
0 points: I haven't lost much weight, if any, lately.
1 point: I have lost more than five pounds.
2 points: I have lost more than 10 pounds.
3 points: I have lost more than 15 pounds.

Question 20

Rows	Choose One
0 points: I am no more worried about my health than usual.
1 point: I am worried about physical problems like aches, pains, upset stomach, or constipation.
2 points: I am very worried about physical problems and it's hard to think of much else.
3 points: I am so worried about my physical problems that I cannot think of anything else.

Question 21

Rows	Choose One
0 points: I have not noticed any recent change in my interest in sex.
1 point: I am less interested in sex than I used to be.
2 points: I have almost no interest in sex.
3 points: I have lost interest in sex completely.

Total Score: Add up the points for each of the 21 questions and enter here.*
Adverse Childhood Experiences

Select Yes or No for each question.

Prior to your 18th birthday

Rows	No	Yes
Did a parent or other adult in the household often or very often... Swear at you, insult you, put you down, or humiliate you? or act in a way that made you afraid that you might be physically hurt?
Did a parent or other adult in the household often or very often... Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
Did an adult or person at least 5 years older than you ever... Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
Did you often or very often feel that ... No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
Did you often or very often feel that ... You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Was a biological parent ever lost to you through divorce, abandonment, or other reason?
Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
Did a household member go to prison?
Were any of your parents or adult caregivers: Often or very often pushed, grabbed, slapped, or had something thrown at her? Or, sometimes, often, or very often kicked, bitten, hit with a fist or hit with something hard? Or ever repeatedly hit over at least a few minutes or threatened with a gun?
Was a household member depressed or mentally ill, or did a household member attempt suicide?

How many questions did you mark yes?*
Should be Empty:

Krippa Family Psychological & Wellness Services

Mental Health Questionnaires

GAD-7 Anxiety

Beck Depression Inventory

Adverse Childhood Experiences