"*" indicates required fields Step 1 of 11 9% Evaluation FormFirst Name*Surname*Today's Date* DD slash MM slash YYYY Question 10Below are ten statements about yourself which may or may not be true. Using the 1-4 scale below, please indicate your agreement with each item by placing the appropriate number in the box following that item. Please be open and honest in your responding The 4-point scale: 1 2 3 4 Not at all true Hardly true Moderately true Exactly true 10.1 I can always manage to solve difficult problems if I try hard enough.* 1 - Not at all true 2 - Hardly true 3 - Moderately true 4 - Exactly true 10.2 If someone opposes me, I can find the means and way to get what I want.* 1 - Not at all true 2 - Hardly true 3 - Moderately true 4 - Exactly true 10.3 It is easy for me to stick to my aims and accomplish my goals.* 1 - Not at all true 2 - Hardly true 3 - Moderately true 4 - Exactly true 10.4 I am confident that I could deal efficiently with unexpected events.* 1 - Not at all true 2 - Hardly true 3 - Moderately true 4 - Exactly true 10.5 Thanks to my resourcefulness, I know how to handle unforeseen situations.* 1 - Not at all true 2 - Hardly true 3 - Moderately true 4 - Exactly true 10.6 I can solve most problems if I invest the necessary effort.* 1 - Not at all true 2 - Hardly true 3 - Moderately true 4 - Exactly true 10.7 I can remain calm when facing difficulties because I can rely on my coping abilities.* 1 - Not at all true 2 - Hardly true 3 - Moderately true 4 - Exactly true 10.8 When I am confronted with a problem, I can usually find several solutions.* 1 - Not at all true 2 - Hardly true 3 - Moderately true 4 - Exactly true 10.9 If I am in trouble, I can usually think of a solution.* 1 - Not at all true 2 - Hardly true 3 - Moderately true 4 - Exactly true 10.10 I can usually handle whatever comes my way.* 1 - Not at all true 2 - Hardly true 3 - Moderately true 4 - Exactly true Question 11Below are some statements about feelings and thoughts. Please tick the box that best describes your experience of each over the last 2 weeks.11.1 I've been feeling optimistic about the future* None of the time Rarely Some of the time Often All of the time 11.2 I've been feeling useful* None of the time Rarely Some of the time Often All of the time 11.3 I've been feeling relaxed* None of the time Rarely Some of the time Often All of the time 11.4 I've been dealing with problems well* None of the time Rarely Some of the time Often All of the time 11.5 I've been thinking clearly* None of the time Rarely Some of the time Often All of the time 11.6 I've been feeling close to other people* None of the time Rarely Some of the time Often All of the time 11.7 I've been able to make up my own mind about things* None of the time Rarely Some of the time Often All of the time Question 12This scale is a ten item Likert scale, with items answered on a four point scale - from strongly agree to strongly disagree. Below is a list of statements dealing with your general feelings about yourself. Please tick the appropriate boxes that best describe your feelings.12.1 On the whole, I am satisfied with myself.* Strongly Agree Agree Disagree Strongly Disagree 12.2 At times, I think I am no good at all* Strongly Agree Agree Disagree Strongly Disagree 12.3 I feel that I have a number of good qualities.* Strongly Agree Agree Disagree Strongly Disagree 12.4 I am able to do things as well as most other people.* Strongly Agree Agree Disagree Strongly Disagree 12.5 I feel I do not have much to be proud of.* Strongly Agree Agree Disagree Strongly Disagree 12.6 I certainly feel useless at times.* Strongly Agree Agree Disagree Strongly Disagree 12.7 I feel that I'm a person of worth, at least on an equal plane with others.* Strongly Agree Agree Disagree Strongly Disagree 12.8 I wish I could have more respect for myself.* Strongly Agree Agree Disagree Strongly Disagree 12.9 All in all, I am inclined to feel that I am a failure.* Strongly Agree Agree Disagree Strongly Disagree 12.10 I take a positive attitude toward myself.* Strongly Agree Agree Disagree Strongly Disagree Question 13People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity.If you are retired or choose not to have a job for reasons unrelated to your problem: tick here 0 1 2 3 4 5 6 7 8 Not at all true Slightly Definitely Markedly Very Severely 13.1 Because of my mental health my ability to work is impaired.* 0 - Not at all 1 2 - Slightly 3 4 - Definitely 5 6 - Markedly 7 8 - Very severely ("0" means not at all impaired and "8" means very severely impaired to the point I can't work)13.2 Because of my mental health my home management (cleaning, tidying, shopping, cooking, looking after home or children, paying bills) is impaired.* 0 - Not at all 1 2 - Slightly 3 4 - Definitely 5 6 - Markedly 7 8 - Very severely 13.3 Because of my mental health my social leisure activities (with other people e.g. parties, bars, clubs, outings, visits, dating, home entertainment) are impaired.* 0 - Not at all 1 2 - Slightly 3 4 - Definitely 5 6 - Markedly 7 8 - Very severely 13.4 Because of my mental health, my private leisure activities (done alone, such as reading, gardening, collecting, sewing, walking alone) are impaired.* 0 - Not at all 1 2 - Slightly 3 4 - Definitely 5 6 - Markedly 7 8 - Very severely 13.5 Because of my mental health, my ability to form and maintain close relationships with others, including those I live with, is impaired.* 0 - Not at all 1 2 - Slightly 3 4 - Definitely 5 6 - Markedly 7 8 - Very severely Question 14Over the last two weeks, how often have you been bothered by the following problems?14.1 Feeling nervous, anxious, or on edge* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 14.2 Not being able to stop or control worrying* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 14.3 Worrying too much about different things* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 14.4 Trouble relaxing* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 14.5 Being so restless that it is hard to sit still* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 14.6 Becoming easily annoyed or irritable* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 14.7 Feeling afraid, as if something awful might happen* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day Question 15Over the last two weeks, how often have you been bothered by any of the following problems?15.1 Little interest or pleasure in doing things* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 15.2 Feeling down, depressed or hopeless* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 15.3 Trouble falling or staying asleep, or sleeping too much* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 15.4 Feeling tired or having little energy* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 15.5 Poor appetite or overeating* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 15.6 Feeling bad about yourself, or that you are a failure, or have let yourself or your family down* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 15.7 Trouble concentrating on things, such as reading the newspaper or watching television* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 15.8 Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual* 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day Question 1616.1 How often do you feel that you lack companionship?* 1 - Hardly ever 2- Some of the time 3 - Often 16.2 How often do you feel left out?* 1 - Hardly ever 2- Some of the time 3 - Often 16.3 How often do you feel isolated from others?* 1 - Hardly ever 2- Some of the time 3 - Often Question 17We are interested in how you feel about the following statements. Read each statement carefully. Indicate how you feel about each situation.17.1 There is a special person who is around when I am in need* Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree 17.2 There is a special person with whom I can share my joys and sorrows.* Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree 17.3 My family really tries to help me.* Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree 17.4 I get the emotional help and support I need from my family.* Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree 17.5 I have a special person who is a real source of comfort to me.* Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree 17.6 My friends really try to help me.* Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree 17.7 I can count on my friends when things go wrong.* Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree 17.8 I can talk about my problems with my family.* Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree 17.9 I have friends with whom I can share my joys and sorrows.* Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree 17.10 There is a special person in my life who cares about my feelings.* Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree 17.11 My family is willing to help me make decisions.* Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree 17.12 I can talk about my problems with my friends.* Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree Question 1818.1 At work, I feel mentally exhausted* 1 - Never 2 - Rarely 3 - Sometimes 4 - Often 5 - Always 18.2 After a day at work, I find it hard to recover my energy* 1 - Never 2 - Rarely 3 - Sometimes 4 - Often 5 - Always 18.3 At work, I feel physically exhausted* 1 - Never 2 - Rarely 3 - Sometimes 4 - Often 5 - Always 18.4 I struggle to find any enthusiasm for my work* 1 - Never 2 - Rarely 3 - Sometimes 4 - Often 5 - Always 18.5 I feel a strong aversion towards my job* 1 - Never 2 - Rarely 3 - Sometimes 4 - Often 5 - Always 18.6 I'm cynical about what my work means to others* 1 - Never 2 - Rarely 3 - Sometimes 4 - Often 5 - Always 18.7 At work, I have trouble staying focused* 1 - Never 2 - Rarely 3 - Sometimes 4 - Often 5 - Always 18.8 When I'm working, I have trouble concentrating* 1 - Never 2 - Rarely 3 - Sometimes 4 - Often 5 - Always 18.9 I make mistakes in my work because I have my mind on other things* 1 - Never 2 - Rarely 3 - Sometimes 4 - Often 5 - Always 18.10 At work, I feel unable to control my emotions* 1 - Never 2 - Rarely 3 - Sometimes 4 - Often 5 - Always 18.11 I do not recognise myself in the way I react emotionally at work* 1 - Never 2 - Rarely 3 - Sometimes 4 - Often 5 - Always 18.12 At work I may overreact unintentionally* 1 - Never 2 - Rarely 3 - Sometimes 4 - Often 5 - Always Question 1919.1 I tend to bounce back quickly after hard times* 1 - Strongly disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly agree 19.2 I have a hard time making it through stressful events* 1 - Strongly disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly agree 19.3 It does not take me long to recover from a stressful event* 1 - Strongly disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly agree 19.4 It is hard for me to snap back when something bad happens* 1 - Strongly disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly agree 19.5 I usually come through difficult times with little trouble* 1 - Strongly disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly agree 19.6 I tend to take a long time to get over setbacks in my life* 1 - Strongly disagree 2 - Disagree 3 - Neutral 4 - Agree 5 - Strongly agree Question 2020.1 Overall, how satisfied are you with your life nowadays?* 10 Completely 9 8 7 6 5 4 3 2 1 0 Not at all 20.2 Overall, to what extent do you feel that the things you do in your life are worthwhile?* 10 Completely worthwhile 9 8 7 6 5 4 3 2 1 0 Not at all worthwhile 20.3 Overall, how happy did you feel yesterday?* 10 Completely happy 9 8 7 6 5 4 3 2 1 0 Not at all happy 20.4 Overall, how anxious did you feel yesterday?* 10 Completely anxious 9 8 7 6 5 4 3 2 1 0 Not at all anxious Thank You for taking time to complete this form