Client or clinician to complete this section |
| First: Please tick the ‘Yes’ box if you have had this symptom in the last 30 days. |
| Second: Look back over the questions you have ticked. For every one you answered ‘Yes’, please put a tick in the circle if you had that problem at a time when you were NOT using alcohol or other drugs. |
| 1. Do you often have headaches? |  |
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| 2. Is your appetite poor? | |
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| 3. Do you sleep badly? | |
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| 4. Are you easily frightened? | |
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| 5. Do your hands shake? | |
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| 6. Do you feel nervous? | |
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| 7. Is your digestion poor? | |
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| 8. Do you have trouble thinking clearly? | |
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| 9. Do you feel unhappy? | |
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| 10. Do you cry more than usual? | |
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| 11. Do you find it difficult to enjoy your daily activities? | |
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| 12. Do you find it difficult to make decisions? | |
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| 13. Is your daily work suffering? | |
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| 14. Are you unable to play a useful part in life? | |
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| 15. Have you lost interest in things? | |
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| 16. Do you feel that you are a worthless person? | |
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| 17. Has the thought of ending your life been on your mind? | |
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| 18. Do you feel tired all the time? | |
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| 19. Do you have uncomfortable feelings in the stomach? | |
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| 20. Are you easily tired? | |
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| Show / Hide the correct answers. | |||||
