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MHP: Program Evaluation

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23Questions

HIPAA

Compliance

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    Check all that apply:
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    Check all that apply:
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    Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month. In the past month, how much were you bothered by: 0 Not at all 1 A little bit 2 Moderately 3 Quite a bit 4 Extremely
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    The following questions ask about how you have been feeling during the past 30 days. For each question, please circle the number that best describes how often you had this feeling.
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    The next few questions are about how these feelings may have affected you in the past 30 days. You need not answer these questions if you answered “None of the time” to all of the six questions about your feelings.

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    During the past 30 days, how many days out of 30 were you totally unable to work or
    carry out your normal activities because of these feelings?    *

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    Not counting the days you reported in response to Q3, how many days in the past
    30 were you able to do only half or less of what you would normally have been able
    to do, because of these feelings?    *

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    During the past 30 days, how many times did you see a doctor or other health
    professional about these feelings?    *

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    The following questions ask about how you have been feeling during the past 30 days. For each question, please circle the number that best describes how often you had this feeling.
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    Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month. Over the last 2 weeks, have you felt bothered by any of these things?: 0 Not at all 1 Several Days 2 More than half the days 3 Nearly Every day
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