Outcome Questionnaire

Outcome Questionnaire

This questionnaire is required by Medicaid for clients at the start of therapy and ongoing each month.
Client Name

First NameLast Name
Today's Date

MonthDayYear
Date
INSTRUCTIONS: Looking back over the last week, including today, help us understand how you have been feeling. Read each item carefully and fill the circle completely under the category which best describes your current situation. For this questionnaire, work is defined as employment, school, housework, volunteer work, and so forth.

Rows	Never	Rarely	Sometimes	Frequently	Almost Always
1. I have trouble falling asleep or staying asleep.
2. I feel no interest in things.
3. I feel stressed at work, school or other daily activities.
4. I blame myself for things
5. I am satisfied with my life.
6. I feel irritated.
7. I have thoughts of ending my life.
8. I feel weak.
9. I find my work/school or other daily activities satisfying.
10. I feel fearful.
11. I use alcohol or a drug to get going in the morning.
12. I feel worthless.
13. I am concerned about family troubles.
14. I feel lonely.
15. I have frequent arguments.
16. I have difficulty concentrating.
17. I feel hopeless about the future.
18. I am a happy person.
19. Disturbing thoughts come into my mind that I cannot get rid of.
20. People criticize my drinking (or drug use). (If not applicable, …… mark "never".)
21. I have an upset stomach.
22. I am not working/studying as well as I used to.
23. I have trouble getting along with friends and close acquaintances.
24. I have trouble at work/school or other daily activities because …….. of drinking or drug use. (If not applicable, mark "never".)
25. I feel that something bad is going to happen.
26. I feel nervous.
27. I feel that I am not doing well at work/school or in other daily activities.
28. I feel something is wrong with my mind.
29. I feel blue.
30. I am satisfied with my relationships with others.