New Patient Questionnaire (Part 2)

 Male      Female


(Please include area code)


Instructions:
Please answer the following questions. More questions may appear as you go, so please start at the top and work your way down.

If unsure about a question, leave it unanswered.

SHEEHAN DISABILITY SCALE



Select a number on the scale from 0 to 10 that best describes your situation during the month, which has just ended.



WORK



Because of my problems my work is impaired:

  •  0: not at all
  •  1: mildly
  •  2: mildly
  •  3: mildly
  •  4: moderately
  •  5: moderately
  •  6: moderately
  •  7: markedly
  •  8: markedly
  •  9: markedly
  •  10: very severely (cannot work)


SOCIAL (with other people at parties, socializing, visiting, dating, outings, clubs, entertaining)



Because of my problem my social life is impaired:

  •  0: not at all
  •  1: mildly
  •  2: mildly
  •  3: mildly
  •  4: moderately
  •  5: moderately
  •  6: moderately
  •  7: markedly
  •  8: markedly
  •  9: markedly
  •  10: very severely (never do)


FAMILY LIFE/HOME RESPONSIBILITIES (relating to family members, paying bills, managing home, shopping, cleaning)



Because of my problems my family life/home responsibilities is impaired:

  •  0: not at all
  •  1: mildly
  •  2: mildly
  •  3: mildly
  •  4: moderately
  •  5: moderately
  •  6: moderately
  •  7: markedly
  •  8: markedly
  •  9: markedly
  •  10: very severely (never do)


PERSONALITY QUESTIONNAIRE



These questions are about the kind of person you generally are - that is, how you have usually felt or behaved over the past several years. Select "YES" if the question completely or mostly applies to you, or select "NO" if it does not apply to you. If you do not understand a question or are not sure of your answer, leave it blank.



Have you avoided jobs or tasks that involved having to deal with a lot of people?

  •  YES
  •  NO


Do you avoid getting involved with people unless you are certain they will like you?

  •  YES
  •  NO


Do you find it hard to be "open" even with people you are close to?

  •  YES
  •  NO


Do you often worry about being criticized or rejected in social situations?

  •  YES
  •  NO


Are you usually quiet when you meet new people?

  •  YES
  •  NO


Do you believe that you're not as good, as smart, or as attractive as most other people?

  •  YES
  •  NO


Are you afraid to try new things?

  •  YES
  •  NO


Do you need a lot of advice or reassurance from others before you can make everyday decisions - like what to wear or what to order in a restaurant?

  •  YES
  •  NO


Do you depend on other people to handle important areas in your life such as finances, child care, or living arrangements?

  •  YES
  •  NO


Do you find it hard to disagree with people even when you think they are wrong?

  •  YES
  •  NO


Do you find it hard to start or work on tasks when there is no one to help you?

  •  YES
  •  NO


Have you often volunteered to do things that are unpleasant?

  •  YES
  •  NO


Do you usually feel uncomfortable when you are by yourself?

  •  YES
  •  NO


When a close relationship ends, do you feel you immediately have to find someone else to take care of you?

  •  YES
  •  NO


Do you worry a lot about being left alone to take care of yourself?

  •  YES
  •  NO


Are you the kind of person who focuses on details, order, and organization or likes to make lists and schedules?

  •  YES
  •  NO


Do you have trouble finishing jobs because you spend so much time trying to get things exactly right?

  •  YES
  •  NO


Do you or other people feel that you are so devoted to work (or school) that you have no time left for anyone else or for just having fun?

  •  YES
  •  NO


Do you have very high standards about what is right and what is wrong?

  •  YES
  •  NO


Do you have trouble throwing things out because they might come in handy some day?

  •  YES
  •  NO


Is it hard for you to let other people help you unless they agree to do things exactly the way you want?

  •  YES
  •  NO


Is it hard for you to spend money on yourself and other people even when you have enough?

  •  YES
  •  NO


Are you often so sure you are right that it doesn't matter what other people say?

  •  YES
  •  NO


Have other people told you that you are stubborn or rigid?

  •  YES
  •  NO


When someone asks you to do something that you don't want to do, do you say "yes" but then work slowly or do a bad job?

  •  YES
  •  NO


If you don't want to do something, do you often just "forget" to do it?

  •  YES
  •  NO


Do you often feel that other people don't understand you, or don't appreciate how much you do?

  •  YES
  •  NO


Are you often grumpy and likely to get into arguments?

  •  YES
  •  NO


Have you found that most of your bosses, teachers, supervisors, doctors, and others who are supposed to know what they are doing really don't?

  •  YES
  •  NO


Do you often think that it's not fair that other people have more than you do?

  •  YES
  •  NO


Do you often complain that more than your share of bad things have happened to you?

  •  YES
  •  NO


Do you often angrily refuse to do what others want and then later feel bad and apologize?

  •  YES
  •  NO


Do you usually feel unhappy or that life is no fun?

  •  YES
  •  NO


Do you believe that you are basically an inadequate person and often don't feel good about yourself?

  •  YES
  •  NO


Do you often put yourself down?

  •  YES
  •  NO


Do you keep thinking about bad things that have happened in the past or worry about bad things that might happen in the future?

  •  YES
  •  NO


Do you often judge others harshly and easily find fault with them?

  •  YES
  •  NO


Do you think that most people are basically no good?

  •  YES
  •  NO


Do you almost always expect things to turn out badly?

  •  YES
  •  NO


Do you often feel guilty about things you have or haven't done?

  •  YES
  •  NO


Do you often have to keep an eye out to stop people from using you or hurting you?

  •  YES
  •  NO


Do you spend a lot of time wondering if you can trust your friends or the people you work with?

  •  YES
  •  NO


Do you find that it is best not to let other people know much about you because they will use it against you?

  •  YES
  •  NO


Do you often detect hidden threats or insults in things people say or do?

  •  YES
  •  NO


Are you the kind of person who holds grudges or takes a long time to forgive people who have insulted or slighted you?

  •  YES
  •  NO


Are there many people you can't forgive because they did or said something to you a long time ago?

  •  YES
  •  NO


Do you often get angry or lash out when someone criticizes or insults you in some way?

  •  YES
  •  NO


Have you often suspected that your spouse or partner has been unfaithful?

  •  YES
  •  NO


When you are out in public and see people talking, do you often feel that they are talking about you?

  •  YES
  •  NO


Do you often get the feeling that things that have no special meaning to most people are really meant to give you a message?

  •  YES
  •  NO


When you are around people, do you often get the feeling that you are being watched or stared at?

  •  YES
  •  NO


Have you ever felt that you could make things happen just by making a wish or thinking about them?

  •  YES
  •  NO


Have you had personal experiences with the supernatural?

  •  YES
  •  NO


Do you believe that you have a "sixth sense" that allows you to know and predict things that others can't?

  •  YES
  •  NO


Does it often seem that objects or shadows are really people or animals or that noises are actually people's voices?

  •  YES
  •  NO


Have you had the sense that some person or force is around you, even though you cannot see anyone?

  •  YES
  •  NO


Do you often see auras or energy fields around people?

  •  YES
  •  NO


Are there very few people that you're really close to outside of your immediate family?

  •  YES
  •  NO


Do you often feel nervous when you are with other people?

  •  YES
  •  NO


Is it NOT important to you whether you have any close relationships?

  •  YES
  •  NO


Would you almost always rather do things alone than with other people?

  •  YES
  •  NO


Could you be content without ever being sexually involved with anyone?

  •  YES
  •  NO


Are there really very few things that give you pleasure?

  •  YES
  •  NO


Does it NOT matter to you what people think of you?

  •  YES
  •  NO


Do you find that nothing makes you very happy or very sad?

  •  YES
  •  NO


Do you like to be the center of attention?

  •  YES
  •  NO


Do you flirt a lot?

  •  YES
  •  NO


Do you often find yourself "coming on" to people?

  •  YES
  •  NO


Do you try to draw attention to yourself by the way you dress or look?

  •  YES
  •  NO


Do you often make a point of being dramatic and colorful?

  •  YES
  •  NO


Do you often change your mind about things depending on the people you're with or what you have just read or seen on TV?

  •  YES
  •  NO


Do you have lots of friends that you are very close to?

  •  YES
  •  NO


Do people often fail to appreciate your very special talents or accomplishments?

  •  YES
  •  NO


Have people told you that you have too high an opinion of yourself?

  •  YES
  •  NO


Do you think a lot about the power, fame, or recognition that will be yours someday?

  •  YES
  •  NO


Do you think a lot about the perfect romance that will be yours someday?

  •  YES
  •  NO


When you have a problem, do you almost always insist on seeing the top person?

  •  YES
  •  NO


Do you feel it is important to spend time with people who are special or influential?

  •  YES
  •  NO


Is it very important to you that people pay attention to you or admire you in some way?

  •  YES
  •  NO


Do you think that it's not necessary to follow certain rules or social conventions when they get in your way?

  •  YES
  •  NO


Do you feel that you are the kind of person who deserves special treatment?

  •  YES
  •  NO


Do you often find it necessary to step on a few toes to get what you want?

  •  YES
  •  NO


Do you often have to put your needs above other people's?

  •  YES
  •  NO


Do you often expect other people to do what you ask without question because of who you are?

  •  YES
  •  NO


Are you NOT really interested in other people's problems or feelings?

  •  YES
  •  NO


Have people complained to you that you don't listen to them or care about their feelings?

  •  YES
  •  NO


Are you often envious of others?

  •  YES
  •  NO


Do you feel that others are often envious of you?

  •  YES
  •  NO


Do you find that there are very few people that are worth your time and attention?

  •  YES
  •  NO


Have you often become frantic when you thought that someone you really cared about was going to leave you?

  •  YES
  •  NO


Do your relationships with people you really care about have lots of extreme ups and downs?

  •  YES
  •  NO


Have you all of a sudden changed your sense of who you are and where you are headed?

  •  YES
  •  NO


Does your sense of who you are often change dramatically?

  •  YES
  •  NO


Are you different with different people or in different situations, so that you sometimes don't know who you really are?

  •  YES
  •  NO


Have there been lots of sudden changes in your goals, career plans, religious beliefs, and so on?

  •  YES
  •  NO


Have you often done things impulsively?

  •  YES
  •  NO


Have you tried to hurt or kill yourself or threatened to do so?

  •  YES
  •  NO


Have you ever cut, burned, or scratched yourself on purpose?

  •  YES
  •  NO


Do you have a lot of sudden mood changes?

  •  YES
  •  NO


Do you often feel empty inside?

  •  YES
  •  NO


Do you often have temper outbursts or get so angry that you lose control?

  •  YES
  •  NO


Do you hit people or throw things when you get angry?

  •  YES
  •  NO


Do even little things get you very angry?

  •  YES
  •  NO


When you are under a lot of stress, do you get suspicious of other people or feel especially spaced out?

  •  YES
  •  NO


Before you were 15, would you bully or threaten other kids?

  •  YES
  •  NO


Before you were 15, would you start fights?

  •  YES
  •  NO


Before you were 15, did you hurt or threaten someone with a weapon, like a bat, brick, broken bottle, knife, or gun?

  •  YES
  •  NO


Before you were 15, did you deliberately torture someone or cause someone physical pain and suffering?

  •  YES
  •  NO


Before you were 15, did you torture or hurt animals on purpose?

  •  YES
  •  NO


Before you were 15, did you rob, mug, or forcibly take something from someone by threatening him or her?

  •  YES
  •  NO


Before you were 15, did you force someone to have sex with you, to get undressed in front of you, or to touch you sexually?

  •  YES
  •  NO


Before you were 15, did you set fires?

  •  YES
  •  NO


Before you were 15, did you deliberately destroy things that weren't yours?

  •  YES
  •  NO


Before you were 15, did you break into houses, other buildings, or cars?

  •  YES
  •  NO


Before you were 15, did you lie a lot or "con" other people?

  •  YES
  •  NO


Before you were 15, did you sometimes steal or shoplift things or forge someone's signature?

  •  YES
  •  NO


Before you were 15, did you run away from home and stay away overnight?

  •  YES
  •  NO


Before you were 13, did you often stay out very late, long after the time you were supposed to be home?

  •  YES
  •  NO


Before you were 13, did you often skip school?

  •  YES
  •  NO




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