Information is confidential and only scores rather than answers are recorded.
1. Do you suffer from allergies? a) never b) used to c) mildly d) quite severe e) debilitating (I have seen my G.P. or hospital) 2. Do you suffer from headaches/migraines? a) never b) occasionally get mild headaches c) occasionally get quite severe pain d) Regularly suffer from mild headaches e) regularly suffer from severe headaches 3. Do you suffer from stomach complaints such as irritable bowel syndrome, constipation, diarrhoea? a)never b)occasionally mild symptoms c)occasionally quite severe d)regularly quite mild symptoms have seen or am considering seeing my G.P. e)regularly suffering with severe symptoms 4. Insomnia a) never b) sometimes find it hard to get to sleep c) frequently find it hard to get to sleep d) sometimes find it hard to sleep and or wake early without being able to get back to sleep e) frequently find it hard to sleep and or wake early without being able to get back to sleep 5. Weight a) I have NO concerns regarding my weight b) I have slight concern c) I am often concerned about my weight d) I am always concerned about my weight e) I am worried so much about my weight that I have seen or am considering seeing my G.P. 6. How is your outlook towards : Job a) I am happy in my work or happy not working b) I occasionally feel I want to be doing something else. c) I am recently unemployed or feel stagnated in my job. d) I am struggling to find work or I feel I hate my job e) I find it difficult to get up for work or am off sick with stress related illness. 7. Relationships (love life) a) I am totally in love or blissfully happy being single. b) I am happy in my relationship with my partner or being single. c) I am fairly content but sometimes wonder what things would be like with someone else. d) I am unhappy with my current situation. e) I am extremely unhappy with my current situation. 8. Relationships (family) a) I enjoy spending as much time as I can with my family and have a fantastic relationship with them. b) I enjoy spending time with my family and have a good relationship with them c) I sometimes enjoy spending time with my family. d) I do not spend much time with my family e) I actively avoid spending any time with my family. 9. Future a) I believe my future is bright and I am excited about my future plans. b) I make plans for my future but they might not happen. c) I make some plans for my future but it is probably a waste of time. d) I can’t be bothered to make plans for the future because there is no point. e) I am worried that my future will be bad so I try not to think about it. 10. How content are you at the moment? a) I am very happy and content b) I am content c) I am fairly happy d) I am fairly unhappy e) I am very unhappy
