Corey O'Connell's Additional Screening Questions
Generalized Anxiety Screener
Name
First Name
Last Name
In the last two weeks, how often have you been bothered by the following symptoms?
Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious, or on edge
Not being able to stop of control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritated
Feeling afraid as if something awful might happen
If you have experienced any of these symptoms, how difficult have these symptoms made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
When did these symptoms start?
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PCL-5
Below is a list of problems that people have sometimes in response to a very stressful experience. Please read each problem carefully and then select one of the answers 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:
Not at all
A little bit
Moderately
Quite a bit
Extremely
1. Repeated, disturbing, and unwanted memories of the stressful experience?
2. Repeated, disturbing dreams of the stressful experience?
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were reliving it)?
4. Feeling very upset when something reminded you of the stressful experience?
5. Having strong physical reactions when something reminded you of the stressful experience (ex: heart pounding, trouble breathing, sweating, etc)?
6. Avoiding memories, thoughts, or feelings related to the stressful experience?
7. Avoiding external reminders of the stressful experience (ex: people, places, objects, activities, or situations)?
8. Trouble remembering important parts of the stressful experience?
9. Having strong negative beliefs about yourself, other people, or the world, (for example, having thoughts such as: I am bad, there is something wrong with me, no one can be trusted, the world is completely dangerous, etc)?
10. Blaming yourself or someone else for the stressful experience or what happened after it?
11. Having strong negative feelings such as fear, horror, shame, guilt, or anger?
12. Loss of interest in activities that you used to enjoy?
13. Feeling distant or cut off from other people?
14. Trouble experiencing positive feelings (ex: being unable to feel happiness, or have loving feelings for people close to you)?
15. Irritable behavior, angry outbursts, or acting aggressively?
16. Taking too many risks or doing things that could cause you harm?
17. Being super alert, watchful, or on guard?
18. Feeling jumpy or easily startled?
19. Having difficulty concentrating?
20. Trouble falling or staying asleep?
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Patient Health Questionnaire-9 (PHQ-9)
Over the last 2 weeks, how much have you been bothered by the following symptoms?
Over the last 2 weeks, how much have you been bothered by the following symptoms?
Not at all
Several days
More than half the days
Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or over eating
6. Feeling bad about yourself...or that you are a failure or have let yourself down or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite...being so restless or moving around a lot more than usual
9. Thoughts that you would be better off dead, or thoughts of hurting yourself
If you checked off any of these problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
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Suicide Ideation Intensity
Reminder: We do not offer crisis counseling support. If you are in crisis please call 9-8-8. (988 is the new three-digit dialing code that will route you to the crisis lifeline via phone call, text or chat. You will be able to speak with trained counselors that will help provide understanding, support and connection to resources) Beneficial Numbers to save: Tampa Mobile Crisis Unit: 813-272-2958: Gracepoint Mobile Crisis Response Team serves children (5 to 17) or adults who are threatening suicide or depressed and are available by phone or detailed evaluations at home, school or workplace to determine when behavioral crisis care is appropriate. Crisis TEXT line (text MHA to 741-741) for text based crisis support.
How many times have you had thoughts of wanting to kill yourself or wanting to die?
Less than once a week
Once a week
2-5 times a week
Daily or almost daily
Many times a day
When you have these thoughts, how long do they last?
Fleeting- a few seconds or minutes
Less than 1 hour/some of the time
1-4 hours/a lot of time
4-8 hours/most of the day
More than 8 hours/persistent or continuous
Could/can you stop thinking about killing yourself or wanting to die if you want to?
Easily able to control thoughts
Can control thoughts with little difficulty
Can control thoughts with some difficulty
Can control thoughts with a lot of difficulty
Unable to control thoughts
Do not attempt to control thoughts
Are there things - anyone or anything (family, friends, religion, pain of death)that stopped you from wanting to die or acting on thoughts of committing suicide?
Deterrents definitely stopped you from attempting suicide
Deterrents probably stopped you
Uncertain that deterrents stopped you
Deterrents most likely did not stop you
Deterrents did not stop you
Does not apply
What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it to end the pain or stop the way you were feeling or was it to get attention, revenge, or a reaction from others? Or both?
Completely to get attention or a reaction from others
Mostly to get attention, revenge, or a reaction from others
Equally to get attention, revenge, or a reaction from others and wanting to stop the pain
Mostly to stop or end the pain
Completely to stop or end the pain
Does not apply
Submit
Should be Empty: