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General H Q
General H Q
General H Q
Name:_________________________ Date:_______________
Please read this carefully. We should like to know if you have had any medical complaints and how your health has
been in general, over the past few weeks. Please answer ALL the questions on the following pages simply by
underlining the answer which you think most nearly applies to you. Remember that we want to know about present
and recent complaints, not those that you had in the past. It is important that you try to answer ALL the questions.
Thank you very much for your co-operation.
Questions
B2. Had difficulty in staying asleep more once you are off?
0 Not at all.
1 No more than usual.
2 Rather more than usual.
3 Much more than usual.
C4. Been satisfied with the way you’ve carried out your task?
0 More Satisfied.
1 About same as usual.
2 Less satisfied than usual.
3 Much less and satisfied
D4. Thought of the possibility that you might make away with yourself?
0 Definitely not.
1 I don’t think so.
2 Has crossed my mind.
3 Definitely has.
D5. Found at times you couldn’t do anything because your nerves were too bad?
0 Not at all.
1 No more than usual.
2 Rather more than usual.
3 Much more than usual
D6. Found yourself wishing you were dead and away from it all?
0 Not at all.
1 No more than usual.
2 Rather more than usual.
3 Much more than usual
D7. Found that the idea of taking your own life kept coming into your mind?
0 Definitely not.
1 I don’t think so.
2 Has crossed my mind.
3 Definitely has.
A B C D Total