Quality of Life Questionnaire in Gastroesophageal Reflux
|
|
- Rosalyn Leonard
- 6 years ago
- Views:
Transcription
1 Quality of Life Questionnaire in Gastroesophageal Reflux Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 1
2 How to complete the questionnaire The following questions are about your health during the past 4 weeks. Please answer all questions by circling only one number per question. Choose the response that best describes how you feel or how you have felt during the past 4 weeks. Example: During the past 4 weeks, because of your digestive problems, have you been bothered by stomach pains? Not applicable Please, answer every question even if some of them seem similar to you. If you do not participate in certain activities (ex: sports, gardening,...) circle 0 for "Not applicable". If you make a mistake, please cross out the wrong answer and circle the one that best applies to you. We would like you to try to answer this questionnaire on your own. Thank you for your participation. Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 2
3 Daily life 1. During the past 4 weeks, because of your digestive problems, have you felt uncomfortable when bending down to put your shoes or socks on? 2. During the past 4 weeks, because of your digestive problems, have you had difficulty doing things that needed to be done with as much attention as usual? 3. During the past 4 weeks, because of your digestive problems, have you done less than usual? 4. During the past 4 weeks, have you consciously avoided movements that might have made your digestive problems worse? 5. During the past 4 weeks, have you been bothered by your digestive problems when gardening, doing odd jobs or doing housework? Not applicable 0 6. During the past 4 weeks, have you been bothered by your digestive problems when wearing tight clothes? Not applicable 0 Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 3
4 Relationships 7. During the past 4 weeks, have you felt embarrassed because of your digestive problems when having meals with others? 8. During the past 4 weeks, have you felt embarrassed because of your digestive problems at times other than during meals? Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 4
5 Quality of life 9. During the past 4 weeks, have you been able to lead a relatively normal life even though you have digestive problems? 10. During the past 4 weeks, have you felt satisfied with your life in general even though you have digestive problems? 11. During the past 4 weeks, have you felt tired because of your digestive problems? 12. During the past 4 weeks, have you felt exhausted because of your digestive problems? 13. During the past 4 weeks, have you felt good about yourself even though you have digestive problems? 14. During the past 4 weeks, because of your digestive problems, have you felt like not performing certain activities or doing certain things? Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 5
6 15. During the past 4 weeks, considering your digestive problems, have you enjoyed your favorite leisure activities? 16. During the past 4 weeks, considering your digestive problems, have you enjoyed food? Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 6
7 State of mind 17. During the past 4 weeks, have you been worried because of your digestive problems? 18. During the past 4 weeks, have your digestive problems disturbed your quality of life? 19. During the past 4 weeks, have you felt obsessed with your digestive problems? 20. During the past 4 weeks, because of your digestive problems, have you been irritated? 21. During the past 4 weeks, because of your digestive problems, have you been in a bad mood? 22. During the past 4 weeks, have you felt as if your digestive problems were a handicap? 23. During the past 4 weeks, have your digestive problems been a source of discomfort? Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 7
8 Worries and concerns 24. Are you worried that you won't find a solution to your digestive problems? 25. Are you worried your digestive problems will get worse? 26. Are you worried that you have a serious illness? 27. Are you worried you will need an operation for your digestive problems? 28. Are you worried that your treatment is no longer effective? Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 8
9 Sleep 29. During the past 4 weeks, considering your digestive problems, have you felt you have had enough sleep? 30. During the past 4 weeks, because of your digestive problems, have you felt anxious about going to bed? 31. During the past 4 weeks, did your digestive problems wake you up from sleep? 32. During the past 4 weeks, have your digestive problems kept you awake most of the night? 33. During the past 4 weeks, when your digestive problems woke you up, did you have difficulty getting back to sleep? Not applicable 0 Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 9
10 Food 34. During the past 4 weeks, after eating, have you had to wait a while before going to bed? 35. During the past 4 weeks, have you had to eat small meals to avoid having digestive problems? 36. During the past 4 weeks, have you avoided eating large meals because you were afraid of having digestive problems? 37. During the past 4 weeks, have your digestive problems been triggered by eating a meal (even a small one) in a stressful or busy environment? Questionnaire developed by laboratoires Houdé, Mapi, M. Amouretti, J.P. Galmiche, T. Poynard 10
QOLRAD QUESTIONNAIRE FOR PATIENTS WITH GASTROINTESTINAL SYMPTOMS PLEASE READ THIS CAREFULLY BEFORE ANSWERING THE QUESTIONS
QOLRAD QUESTIONNAIRE FOR PATIENTS WITH GASTROINTESTINAL SYMPTOMS PLEASE READ THIS CAREFULLY BEFORE ANSWERING THE QUESTIONS On the following pages you will find some questions asking about how you have
More informationQOLRAD QUESTIONNAIRE FOR PATIENTS WITH SYMPTOMS OF HEARTBURN PLEASE READ THIS CAREFULLY BEFORE ANSWERING THE QUESTIONS
QOLRAD QUESTIONNAIRE FOR PATIENTS WITH SYMPTOMS OF HEARTBURN PLEASE READ THIS CAREFULLY BEFORE ANSWERING THE QUESTIONS On the following pages you will find some questions asking about how you have been
More informationThis questionnaire is designed to find out how you have been feeling during the last two weeks. Please circle only one number for each question.
This questionnaire is designed to find out how you have been feeling during the last two weeks. Please circle only one number for each question. 1. How frequent have your bowel movements been during the
More informationPsychological Sleep Services Sleep Assessment
Psychological Sleep Services Sleep Assessment Name Date **************************************************** Insomnia Severity Index For each question, please CIRCLE the number that best describes your
More informationdid you feel sad or depressed? did you feel sad or depressed for most of the day, nearly every day?
Name: Age: Date: PDSQ This form asks you about emotions, moods, thoughts, and behaviors. For each question, circle YES in the column next to that question, if it describes how you have been acting, feeling,
More informationPATIENT NAME: DATE OF DISCHARGE: DISCHARGE SURVEY
PATIENT NAME: DATE OF DISCHARGE: DISCHARGE SURVEY Please indicate whether you feel Living Hope Eating Disorder Treatment Center provided either Satisfactory or Unsatisfactory service for each number listed
More informationINSOMNIA SEVERITY INDEX
Name: Date: INSOMNIA SEVERITY INDEX For each of the items below, please circle the number that most closely corresponds to how you feel. 1. Please rate the CURRENT (i.e. last 2 weeks) severity of your
More informationMedicare Wellness Visit
of Birth: Today s : Medicare Wellness Visit Dear Patient, Your Medicare benefits include an Annual Wellness Visit to assist in preventing illness or detect illness at an early stage. Your Annual Wellness
More informationPrimary Care Tool for Assessment of Depression during Pregnancy and Postpartum
HRSA-UIC Assessment of Depression Perinatal during Pregnancy Project: and Postpartum Primary Care Tool for Assessment of Depression during Pregnancy and Postpartum te to health care provider: This tool
More informationHow to Exercise with CFS
How to Exercise with CFS To equip people affected by CFS / ME with the skills for self-management towards a better quality of life. Adult CFS / ME Service January 2018 Review January 2019 HOW CAN I EXERCISE
More informationPediatric Restless Legs Syndrome Severity Scale Parent Questionnaire. Weekly Diary. Instructions:
Pediatric Restless Legs Syndrome Severity Scale Parent Questionnaire Weekly Diary Questions 1-17 all ask about your child. Instructions: Answer thinking about your child during during the past 7 days.
More informationSUPPLEMENT MATERIALS. Appendix A: Cleveland Global Quality of Life (CGQL) [0 being the WORST and 10 being the BEST]
SUPPLEMENT MATERIALS Appendix A: Cleveland Global Quality of Life (CGQL) [0 being the WORST and 10 being the BEST] Q1. Current Quality of Life: Circle one 6 7 8 9 10 Q2. Current Quality of Health: Circle
More informationPittsburgh Insomnia Rating Scale University of Pittsburgh School of Medicine, Department of Psychiatry, All Rights Reserved.
Pittsburgh Insomnia Rating Scale University of Pittsburgh School of Medicine, Department of Psychiatry, 2001. All Rights Reserved. Name ID# Date A. Overall sleep quality: Consider the quality of your sleep
More informationA Guide To Fibromyalgia
What Is Fibromyalgia? Fibromyalgia is a chronic condition that affects about 5 million Americans. Doctors diagnose fibromyalgia based on a patient's symptoms and physical exam. Patients experience pain
More informationo never o 1 day per week or less o 2-3 days per week o 4-6 days per week o every day
Quality of Life Questionnaire Qualeffo-41 (10 December 1997) Users of this questionnaire (and all authorized translations) must adhere to the user agreement. Please use the related Scoring Algorithm. A
More informationSleep Health Center. You have been scheduled for an Insomnia Treatment Program consultation to further discuss your
Sleep Health Center You have been scheduled for an Insomnia Treatment Program consultation to further discuss your sleep. In the week preceding your appointment, please take the time to complete the enclosed
More informationCoach on Call. Letting Go of Stress. A healthier life is on the line for you! How Does Stress Affect Me?
Coach on Call How Does Stress Affect Me? Over time, stress can affect the way you feel, think, and act. You need some time when you are free of stress. You need ways to get relief from stress. Without
More informationKAISER PERMANENTE SPINE
KAISER PERMANENTE SPINE The following forms are specially designed to give your doctor valuable information about the health of your spine. The same way an EKG gives us information about your heart. It
More informationExercises for Chronic Pain
Exercises for Chronic Pain Many research studies show aerobic and strengthening exercises can lessen chronic pain and improve a person s ability to do daily activities. What is Exercise? It is any activity
More informationUSF Mood & Anxiety Disorders Program
QUICK INVENTORY OF DEPRESSIVE SYMPTOMATOLOGY (SELF-REPORT)(QIDS-SR16) Please circle the one response to each item that best describes you for the past seven days. 1. Falling Asleep: 0 I never take longer
More informationNational Institute on Drug Abuse (NIDA) What is Addiction?
National Institute on Drug Abuse (NIDA) What is Addiction? https://www.drugabuse.gov 1 Table of Contents What is Addiction? Do You or a Loved One Have a Drug Abuse Problem? Signs of Drug Abuse and Addiction
More informationOverall, how would you rate your mental health on a scale from 1 to 7, where 1 is poor, 4 is average, 7 excellent?
Question: 300 0> SKIP THE SECTION ON WELL-BEING 1> ASK THE SECTION ON WELL-BEING Question: 301 The next several questions ask you about your personal well-being. Overall, how would you rate your physical
More informationInformation for young people about depression
Depression hos unge, engelsk Information for young people about depression The disorder, its treatment and prevention Psykiatri og Social psykinfomidt.dk Contents 03 What is depression? 03 What are the
More informationWELLBEING GUIDE. This guidance is for anyone who wants to know how to deal with stress and how to learn to relax
WELLBEING GUIDE This guidance is for anyone who wants to know how to deal with stress and how to learn to relax Human Resources October 2016 Contents Introduction... 2 Section 1... 2 Stress... 2 1.1 What
More informationCreated by Support Plus, 2017 Sleep
Created by Support Plus, 2017 Sleep You might want to look at this leaflet with someone you trust like a healthcare worker Sleep Contents Page Sleep Facts Page 3, 4 and 5 Sleep Problems Page 6 Why do people
More informationWHAT IS STRESS? increased muscle tension increased heart rate increased breathing rate increase in alertness to the slightest touch or sound
EXAM STRESS WHAT IS STRESS? Stress is part of the body s natural response to a perceived threat. We all experience it from time to time. When we feel under threat, our bodies go into fight or flight response,
More informationHYPERSOMNIA NEW PATIENT QUESTIONNAIRE please fax back to us at : Current Medications:
HYPERSOMNIA NEW PATIENT QUESTIONNAIRE please fax back to us at 404-712-8145: Name: Date: Date of Birth: Sex: M F (circle) Height: Weight: Current Medications: At what age did your sleepiness begin? years
More informationInterventional and Vascular Consultants, PC P: F:
Date: Patient Name: Date of Birth: / / Age: Sex: Male Female Referring Physician/Specialist: Varicose Vein Questionnaire 1. During the past 4 s, how often have you had the following leg problems? Heavy
More informationBecause the more you know, the better you ll feel.
ABOUT ASTHMA Because the more you know, the better you ll feel. This booklet is designed to help you understand asthma and the things you can do every day to help control symptoms. As always, talk to your
More informationPEDIATRIC PAIN QUESTIONNAIRE Form A (Adolescent)
PEDIATRIC PAIN QUESTIONNAIRE Form A (Adolescent) Daniel P. Kohen, M.D. Developmental-Behavioral Pediatrics Partners-in-Healing of Minneapolis 10505 Wayzata Blvd - Suite 200 Minnetonka, MN 55305 763-546-5797
More informationWhat is Stress? What causes stress?
What is Stress? Stress is the physical and mental response of the body to demands made upon it by everyday life, especially if we are struggling to cope with pressured or difficult tasks or circumstances.
More informationSleep Self-Assessment
We are pleased you are taking the time to become more aware of your sleep patterns and discover strategies for improving your sleep. You deserve to get a good night s sleep we re here to help! The following
More informationGENERAL BEHAVIOR INVENTORY Self-Report Version Never or Sometimes Often Very Often
GENERAL BEHAVIOR INVENTORY Self-Report Version Here are some questions about behaviors that occur in the general population. Think about how often they occur for you. Using the scale below, select the
More informationMajor Depressive Disorder Wellness Workbook
Framing Major Depressive Disorder Major Depressive Disorder Wellness Workbook This Workbook belongs to you and you decide how to use it. You decide who to show it to and whether or not you want someone
More informationTake Charge of Your Pain Program: Patient Booklet
Take Charge of Your Pain Program: Patient Booklet TABLE OF CONTENTS ABOUT THIS BOOKLET... 3 THINGS TO KNOW ABOUT PAIN... 4 Pain Gate... 6 BECOMING MORE ACTIVE... 7 RELAXATION... 8 DEEP BREATHING... 9 IMAGERY...
More informationBecause the more you know, the better you ll feel.
ABOUT ASTHMA Because the more you know, the better you ll feel. What You ll Find Attitudes and Beliefs Asthma What Is It? Where You ll Find It Page 4-5 This booklet is designed to help you understand asthma
More informationHere are a few ideas to help you cope and get through this learning period:
Coping with Diabetes When you have diabetes you may feel unwell and have to deal with the fact that you have a life long disease. You also have to learn about taking care of yourself. You play an active
More informationEATING QUESTIONNAIRE
ID: Date: EATING QUESTIONNAIRE Instructions: The following questions are concerned with the past four weeks (28 days) only. Please read each question carefully. Please answer all of the questions. Please
More informationQuality of Life Questionnaire for Patients with Thyroid Disease
Quality of Life Questionnaire for Patients with Thyroid Disease -ThyPROus- This questionnaire is about how your thyroid disease has affected your life. Please answer each question by marking by the answer
More informationSMOKING HISTORY INSTRUCTIONS
INSTRUCTIONS SMOKING HISTORY Please answer the following questions based on your experiences with smoking. Each question allows you to choose from several alternatives. Please select one of the alternatives
More informationMOTOR VEHICLE ACCIDENT PAIN CHART
MOTOR VEHICLE ACCIDENT PAIN CHART Name Today s Date (D/M/Y) Area of Concern What is the WORST pain you have ever experienced? (other than the pain you are experiencing NOW!) What was the date of this painful
More informationMORNINGNESS-EVENINGNESS QUESTIONNAIRE Self-Assessment Version (MEQ-SA) 1. Name: Date:
MORNINGNESS-EVENINGNESS QUESTIONNAIRE Self-Assessment Version (MEQ-SA) 1 Name: Date: For each question, please select the answer that best describes you by circling the point value that best indicates
More informationBounce Back. Stronger! Being Emo-chic INFLUENCE INSPIRE IGNITE
INSPIRE IGNITE Bounce Back INFLUENCE Stronger! Being Emo-chic Managing your emotions can sometimes be harder than getting out of bed for school in the mornings. There s always the snooze button if you
More informationPhysical Fitness - Exercises 1
Physical Fitness - Exercises 1 1 Answer the following questions in your own words! Why is being physically active important? What does strength training do to your body? Why won t girls get bigger muscles
More informationACTIVITY - Are you a night owl or an early bird?
ACTIVITY - Are you a night owl or an early bird? Our bodies have an internal clock, called the circadian rhythm, that tells us when it is the best time for us to sleep, wake up, eat, do exercise, learn
More informationPatient Details Hidden. Clinical Enrollment. Quality of Life. EuroQOL (EQ-5D) Enroll Patient. Not Started. Not Started
Patient Details Hidden Show Patient Clinical Enrollment t Started Quality of Life t Started EuroQOL (EQ-5D) Did the patient complete a EuroQOL form? Please select a reason why the EuroQOL was not completed:
More informationManaging Inflammatory Arthritis. What to Discuss with Your Health Care Team
Managing Inflammatory Arthritis What to Discuss with Your Health Care Team Section 1 Introduction What to Discuss with Your Health Care Team This tool has been created with input from patients to provide
More informationCoping with Depression
Coping with Depression How can I help reduce healthcare associated infections? Infection control is important to the well-being of our patients and for that reason we have infection control procedures
More informationX-Plain Exercising For a Healthy Life Reference Summary
X-Plain Exercising For a Healthy Life Reference Summary Introduction By exercising and becoming more active, you can improve your health. People who are not physically active are much more likely to develop
More informationWELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS Prior to your office visit, we request that you complete this questionnaire. It asks questions not only about your sleeping habits and behavior
More informationAxial Spondyloarthritis (axial SpA) Ankylosing Spondylitis (AS) Fatigue. The National Ankylosing Spondylitis NATIONAL ANKYLOSING SPONDYLITIS SOCIETY
Axial Spondyloarthritis (axial SpA) Ankylosing Spondylitis (AS) The National Ankylosing Spondylitis Fatigue Society NATIONAL ANKYLOSING SPONDYLITIS SOCIETY UK What is fatigue? Fatigue is common among people
More informationA1a. Have you ever had a time in your life when you felt sad, blue, or depressed for two weeks or more in a row?
PhenX Measure: General Psychiatric Assessment (#120100) PhenX Protocol: General Psychiatric Assessment - Adult (#120101) Date of Interview/Examination (MM/DD/YYYY): SECTION A: [Major Depressive Episode]
More informationUSE THE LETTERS LISTED BELOW TO INDICATE
USE THE LETTERS LISTED BELOW TO INDICATE THE TYPE AND LOCATION OF YOUR PAIN & SENSATIONS A = ACHE B = BURNING S = STABBING N = NUMBNESS P = PINS & NEEDLES O = OTHER COMMENTS: COMMENTS: PT INITIALS DATE
More informationALVIN C. BURSTEIN, MD PATIENT CLIENT INFORMATION
ALVIN C. BURSTEIN, MD PATIENT CLIENT INFORMATION LEGAL Name Date of Birth (must match insurance card) Address City State Zip Mailing Address City State Zip (If different) Phone: Cell Home Appt. reminders
More informationSleep Management in Parkinson s
Sleep Management in Parkinson s Booklet 1 Introduction An introduction to Sleep Management in Parkinson s Sleep disturbances are commonly experienced by those with Parkinson s, and by the relatives and
More informationRESEARCH STUDY: RELATIONSHIP BETWEEN PAIN AND SLEEP IN SPINAL CORD INJURY PATIENTS Pain perception : McGill Pain Questionnaire
RESEARCH STUDY: RELATIONSHIP BETWEEN PAIN AND SLEEP IN SPINAL CORD INJURY PATIENTS Pain perception : McGill Pain Questionnaire Participants Name: Date: Time: PRI: S A E M PRI (TOTAL) PPI (1-10) (11-15)
More informationManaging Sleep Problems after Cancer
Managing Sleep Problems after Cancer For cancer survivors Read this resource to learn about: What a sleep problem is What causes it What you can do to improve your sleep When to talk to your doctor Please
More informationCHILDHOOD C 3 HANGE CARE TOOL: PROVIDER REPORT
Date: / / Patient s Project ID# For use as-needed in clinic visits A SURVEY TO LEARN ABOUT A PATIENT S NEEDS AND ABILITIES: Health care providers of children and adolescents aged 5 to 2 How is this patient
More informationBrief Pain Inventory (Short Form)
Brief Pain Inventory (Short Form) Study ID# Hospital# Do not write above this line Date: Time: Name: Last First Middle Initial 1) Throughout our lives, most of us have had pain from time to time (such
More informationElbow and Forearm Pain Form
Elbow and Forearm Pain Form Last Name First Name Date RIGHT LEFT My dominant hand? Right Left Does your elbow hurt? Yes No Yes No Does your forearm hurt? Yes No Yes No When did the problem start? Did you
More informationDepression- Information and a self-help guide
Depression- Information and a self-help guide Depression Depression is a very common problem which can affect us in many ways. We can become very low and tearful, have difficulties with our sleep, become
More informationSession 6: Choosing and using HRQoL measures vs Multi-Attribute Utility Instruments QLU-C10D and EQ-5D as examples
Session 6: Choosing and using HRQoL measures vs Multi-Attribute Utility Instruments QLU-C10D and EQ-5D as examples - Madeleine King & Richard De Abreu Lourenco- Overview Learning Objectives To discuss
More informationYOUR SLEEP PATTERNS (for week 0 and week 12)
ID: Page 1 of 1 rev Aug 6, 2014 YOUR SLEEP PATTERNS (for week 0 and week 12) 1. How many hours of sleep do you normally get each night? Typical week night Typical weekend night 2. Do you work at night?
More informationINFORMATION FOR PATIENTS. Let s Manage Pain
INFORMATION FOR PATIENTS Let s Manage Pain 1 About this booklet Persistent pain, also called chronic pain, is pain which continues for longer than expected. Pain can affect all areas of your life. People
More informationConscious Living Counseling & Education Center 3239 Oak Ridge Loop East, West Fargo ND (701)
Conscious Living Counseling & Education Center 3239 Oak Ridge Loop East, West Fargo ND 58078 (701) 478-7199 INTAKE FORM BIRTH DATE: / / Age: Email: YOUR NAME FIRST: MIDDLE INITIAL: LAST: YOUR ADDRESS COMPLETE
More informationa guide to living with ANXIETY Information provided by Mental Health Foundation
www.mentalhealthireland.ie a guide to living with ANXIETY Information provided by Mental Health Foundation 1 a guide to living with anxiety about Mental Health Ireland (MHI) is a national voluntary organisation.
More informationSAN DIEGO SEXUAL MEDICINE
SAN DIEGO SEXUAL MEDICINE INTERNATIONAL INDEX OF ERECTILE FUNCTION (IIEF) These questions ask about the effects that your erection problems have had on your sex life over the last four weeks. Please try
More informationTHE GENERAL WELL-BEING SCHEDULE SEX: M: [ ] F: [ ] AGE: 1. How have you been feeling in general during the past month?
1 THE GENERAL WELL-BEING SCHEDULE NAME: Last First Middle SEX: M: [ ] F: [ ] AGE: READ: This section of the examination contains questions about how you feel and how things have been going with you. For
More informationSeek, Test, Treat and Retain for Vulnerable Populations: Data Harmonization Measure
Seek, Test, Treat and Retain for Vulnerable Populations: Measure MENTAL HEALTH Center for Epidemiologic Studies Depression Scale (CES-D) Reference: Radloff, L.S. (1977). The CES-D Scale: a self-report
More informationDO YOU HAVE ADRENAL FATIGUE?
John B. DeCosmo, DO, PA 4800 4 th Street North, Saint Petersburg, Florida 33703 (727) 498-6488, Fax: (727) 362-6772 drdecosmo@gmail.com DO YOU HAVE ADRENAL FATIGUE? A complete list of your current symptoms
More informationOther significant mental health complaints
Other significant mental health complaints 2 Session outline Introduction to other significant mental health complaints Assessment of other significant mental health complaints Management of other significant
More informationEMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION PART I: PERSONAL INFORMATION STREET ADDRESS CITY/STATE
EMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION PART I: PERSONAL INFORMATION FIRST NAME LAST NAME EMAIL PHONE # STREET ADDRESS CITY/STATE ZIP GENDER: MALE FEMALE TRANSGENER MARITAL STATUS: MARRIED
More informationAustralian Centre for Education in Sleep (ACES)
Australian Centre for Education in Sleep (ACES) High School workbook 1 Table of Contents for High School student workbook Topic Page 1. Introduction Dear Student 1 2. Top five reasons why you need to sleep
More informationkeep track of other information like warning discuss with your doctor, and numbers of signs for relapse, things you want to
Helping you set your brain free from psychosis. www.heretohelp.bc.ca This book was written by Sophia Kelly and the BC Schizophrenia Society, for the BC Partners for Mental Health and Addictions Information.
More informationWaccamaw Chiropractic & Wellness Center
Waccamaw Chiropractic & Wellness Center Dr. John Evans Dr. Jeff Evans 658 Wachesaw Rd. Murrells Inlet, SC 29576 www. waccamawchiropractic.com (843)357-9617 Fax (843)357-9639 DO YOU HAVE ADRENAL FATIGUE?
More informationDBSA Survey Center Depression Experiences and Treatments Survey
Summary Report: May, 2017 BACKGROUND DBSA s was developed to identify experiences and challenges faced by individuals with depression, including what people are looking for in terms of treatment, their
More informationClass #2: ACTIVITIES AND MY MOOD
Class # Class #: ACTIVITIES AND MY MOOD CLASS OUTLINE I. Announcements & Agenda II. III. IV. General Review Personal Project Review Relaxation Exercise V. New Material VI. Personal Project I. Any Announcements?
More informationMEDICAL HISTORY QUESTIONNAIRE
MEDICAL HISTORY QUESTIONNAIRE NAME: SEX: DATE: DOB: AGE: Primary Doctor / Care Manager: Additional doctors to receive sleep study results: Chief sleep related complaint: What made you decide to have this
More informationQUALITY OF LIFE IN EPILEPSY - QOLIE-31 (Version 1.0)
QUALITY OF LIFE IN EPILEPSY - QOLIE-31 (Version 1.0) US English QOLIE-31 Copyright 1993, RAND. All rights reserved. The QOLIE-31 was developed in cooperation with Professional Postgraduate Services. Today
More informationMindfulness-Based Stress Reduction
Mindfulness-Based Stress Reduction Presented by: Trevor McMurray, LCSW, MAC Your Employee Assistance Program Provider Mindfulness is a learned skill where we deliberately focus and pay attention to what
More informationThe Wellbeing Plus Course
The Wellbeing Plus Course Resource: Good Sleep Guide The Wellbeing Plus Course was written by Professor Nick Titov and Dr Blake Dear The development of the Wellbeing Plus Course was funded by a research
More information- copyright
Relaxation Exercises Let s start with breathing! Your breathing is often the first thing to be affected by stress. When we are anxious we tend to hunch up the shoulders and breathe in a more rapid and
More informationA GUIDE TO BETTER SLEEP. Prepared by Dr Grant Willson Director, Sleep and Lifestyle Solutions
A GUIDE TO BETTER SLEEP Prepared by Dr Grant Willson Director, Sleep and Lifestyle Solutions A GUIDE TO BETTER SLEEP Good sleep is one of life s pleasures. Most people can think of a time when they slept
More information[PERSONAL PROFILE] Questionnaire and Getting Started Guide
[PERSONAL PROFILE] Questionnaire and Getting Started Guide All rights reserved. Reproduction in whole or in part is forbidden without the express written consent of Mind Alive Inc. 2014-2015 Mind Alive
More informationDepression Care. Patient Education Script
Everybody has the blues from time to time, or reacts to stressful life events with feelings of anxiety, sadness, or anger. Normally these feelings go away with time but when they persist, and are present
More informationWhat type of medication, vitamins, minerals, etc. are you currently taking? For how long? What for? (ie: Prilosec/6 months/acid Reflux)
What type of medication, vitamins, minerals, etc. are you currently taking? For how long? What for? (ie: Prilosec/6 months/acid Reflux) What previous methods have you tried to alleviate your discomfort
More informationTips For Better Sleep
NHS Fife Department of Psychology Tips For Better Sleep Help Yourself @ moodcafe.co.uk Sleep and sleep problems There is no correct amount of sleep that everyone must have. Sleep is a natural process that
More informationNebraska Bariatric Medicine 8207 Northwoods Dr., Suite 101 Lincoln, NE MEDICAL HISTORY
Nebraska Bariatric Medicine 8207 rthwoods Dr., Suite 101 Lincoln, NE 68505 MEDICAL HISTORY Name Today s Date The following page allows you to complete what we call a weight timeline. This is a very valuable
More informationEnhanced Recovery Patient Diary
Enhanced Recovery Patient Diary I found the diary was helpful. I was able to chart my progress and see a difference. I was eating more each day and able to shower myself. I found it to be encouraging.
More informationIowa Sleep Disturbances Inventory (ISDI)
Department of Psychological & Brain Sciences Publications 1-1-2010 Iowa Sleep Disturbances Inventory (ISDI) Erin Koffel University of Iowa Copyright 2010 Erin Koffel Comments For more information on the
More informationThe Revised Treatment Manual for the Brief Behavioral Activation Treatment for Depression (BATD-R) Pre - Session
The Revised Treatment Manual for the Brief Behavioral Activation Treatment for Depression (BATD-R) Pre-Session Key Elements: 1. Discussion of Depression Pre - Session 2. Introduction to Treatment Rationale
More informationPhase 38 Data Directory SECTION 13 DENTAL HEALTH. Clinical and Oral Examination Socio-dental Questionnaire Examiner Administered Questionnaire
Phase 38 Data Directory SECTION 13 DENTAL HEALTH Clinical and Oral Examination Socio-dental Questionnaire Examiner Administered Questionnaire DMHDS Phase 38 Examiner-administered questionnaire ID No. 1.
More informationTobacco Cessation Toolkit
You notice physical s, like moments of dizziness, sweating, hands trembling or a mild headache. When using tobacco, nicotine increases your heart rate (by about 10 20 beats per minute) and blood pressure.
More informationFor The Instructor. A message to instructors
For The Instructor A message to instructors Mental health is a deeply personal issue that is usually difficult to discuss. Whether concerns revolve around an individual s own mental health concerns or
More information5 Minute Strategies to Support Healthy Treatment and Recovery
HPW-000030 TAKE FIVE 5 Minute Strategies to Support Healthy Treatment and Recovery Below you will find quick strategies, each related to one of 15 different moods commonly experienced by people coping
More informationSTRUCTURED INTERVIEW GUIDE FOR THE HAMILTON ANXIETY SCALE (SIGH-A) Janet B.W. Williams, D.S.W.
STRUCTURED INTERVIEW GUIDE FOR THE HAMILTON ANXIETY SCALE (SIGH-A) Janet B.W. Williams, D.S.W. INTERVIEWER: The questions for each item that appear in bold type should be asked exactly as written. Follow-up
More information#032: HOW TO SAY YOU'RE SICK IN ENGLISH
#032: HOW TO SAY YOU'RE SICK IN ENGLISH Hi, everyone! I'm Georgiana, founder of SpeakEnglishPodcast.com. My mission is to help YOU to speak English fluently and confidently. In today's episode: I'll talk
More informationCHAPTER to. Resting and Sleep
Page Name -- 55 CHAPTER to Resting and Sleep What is sleep? What is rest? Is there a difference between sleeping and resting? Can a person rest without sleeping? Can a person rest even though he is awake?
More informationSUMMARY OF SESSION 6: THOUGHTS ARE NOT FACTS
SUMMARY OF SESSION 6: THOUGHTS ARE NOT FACTS Our thoughts can have powerful effects on how we feel and what we do. Often those thoughts are triggered and occur quite automatically. By becoming aware, over
More informationRefresh. The science of sleep for optimal performance and well being. The Magic of Mindfulness
Refresh The science of sleep for optimal performance and well being Unit 5: The Magic of Mindfulness We realize that everyone has different ideas about how to relax. Some people are more open to alternative
More information