Cohort Survey

Cohort Survey

Please complete this survey based on the original PDF structure. Use the same wording as closely as possible for participant information, consent/background, emergency contact, and mood/depression/anxiety scale items.
Participant Information
First Name
Initial of Last Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address
City
State
Country
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Country of Origin
Nationality
Race / Ethnicity
Gender
Sexual Preference
Patient Identification Number
Consent and Background
Are you willing to participate in a noninvasive research study that includes traditional talk therapy?
Do you have any siblings?
How many girls?
How many boys?
Do you have a support system?
Who will help and listen?
Have you ever experienced domestic violence, sexual assault, or rape?
Current educational level
Emergency Contact
Emergency contact name

First NameMiddle NameLast Name
Emergency contact’s number
Please enter a valid phone number.Format: (000) 000-0000.
Mood, Depression, and Anxiety Scale Items
26. I feel cheerful
27. I feel optimistic about the future
28. I feel that life is worthwhile
29. I feel relaxed
30. I feel interested in other people
31. I have been able to enjoy my normal day-to-day activities
32. I have felt that I am playing a useful part in things
33. I have felt capable of making decisions about things
34. I have felt under strain
35. I have felt I could not overcome my difficulties
36. I have been able to concentrate on what I am doing
37. I have felt sad or depressed
38. I have been losing confidence in myself
39. I have been thinking of myself as a worthless person
40. I have been able to face up to problems
41. I have been feeling reasonably happy, all things considered
42. I have been getting scared or panicky for no very good reason
43. I have felt worried
44. I have felt tense or keyed up
45. I have been able to make up my own mind about things
46. I have been feeling cheerful and in good spirits
47. I have felt as if I were slowed down
48. I have been losing sleep over worry
49. I have been feeling hopeful about the future
50. I have been feeling nervous or on edge
51. I have been able to laugh and see the funny side of things
52. I have felt that I am not doing things well
53. I have been getting upset for no very good reason
54. I have felt that I am not able to cope with all the things that I have to do
55. I have felt useful
56. I have felt panicky
57. I have been able to enjoy a good book or radio or television program
58. I have been feeling unhappy or depressed
59. I have felt restless or fidgety
60. I have felt that everything was getting on top of me
Should be Empty:

Cohort Survey

Participant Information

Consent and Background

Emergency Contact

Mood, Depression, and Anxiety Scale Items