Recite - Accessibility and Language Options

This is the check-in questionnaire for our online classes and courses.

If you have any questions or need help please call us on 02380 383920 and our team will be happy to assist you. You can also email us on info@italk.org.uk.

MDS Questionnaire

Part One: MDS Questionnaire › Review & Submit ›

Your Details

First Name

Last Name

Email Address

Telephone

Postcode

PHQ-9 - Over the last 2 weeks, how often have you been bothered by any of the following problems?		Not at all	Several Days	More than 1/2 the days	Nearly every day
1.	Little interest or pleasure in doing things	Not at all	Several days	More than 1/2 the days	Nearly every day
2.	Feeling down, depressed or hopeless	Not at all	Several days	More than 1/2 the days	Nearly every day
3.	Trouble falling asleep, staying asleep, or sleeping too much	Not at all	Several days	More than 1/2 the days	Nearly every day
4.	Feeling tired or having little energy	Not at all	Several days	More than 1/2 the days	Nearly every day
5.	Poor appetite or overeating	Not at all	Several days	More than 1/2 the days	Nearly every day
6.	Feeling bad about yourself - or that you are a failure or have let yourself or your family down	Not at all	Several days	More than 1/2 the days	Nearly every day
7.	Trouble concentrating on things, such as reading the newspaper or watching television	Not at all	Several days	More than 1/2 the days	Nearly every day
8.	Moving or speaking so slowly that other people could notice, or the opposite - being so fidgety or restless that you have been moving around more than usual	Not at all	Several days	More than 1/2 the days	Nearly every day
9.	Thoughts of being better off dead or hurting yourself in some way	Not at all	Several days	More than 1/2 the days	Nearly every day
If you select "more than half the days" or "nearly every day" on question 9 of the PHQ 9 we recommend you contact your GP to seek advice. We have a duty of care to update your GP (usually by letter) if you select "more than half the days" or "nearly every day" on this question and they may wish to contact you. We will also contact you to offer a telephone assessment.

GAD-7 - Over the last 2 weeks, how often have you been bothered by any of the following problems?		Not at all	Several Days	More than 1/2 the days	Nearly every day
1.	Feeling nervous, anxious or on edge	Not at all	Several days	More than 1/2 the days	Nearly every day
2.	Not being able to stop or control worrying	Not at all	Several days	More than 1/2 the days	Nearly every day
3.	Worrying too much about different things	Not at all	Several days	More than 1/2 the days	Nearly every day
4.	Trouble relaxing	Not at all	Several days	More than 1/2 the days	Nearly every day
5.	Being so restless that it is hard to sit still	Not at all	Several days	More than 1/2 the days	Nearly every day
6.	Becoming easily annoyed or irritable	Not at all	Several days	More than 1/2 the days	Nearly every day
7.	Feeling afraid as if something awful might happen	Not at all	Several days	More than 1/2 the days	Nearly every day

Phobia Scales

Choose a number from the scale below to show how much you avoid each of the situations or objects listed.
Please enter the number in the box opposite the situation.

Would not avoid it
Slightly avoid it
Definitely avoid it
Markedly avoid it
Always avoid it

Situation		Score
1.	Social situations due to a fear of being embarrassed or making a fool of myself
2.	Certain situations because of a fear of having a panic attack or other distressing symptoms (e.g. loss of bladder control, vomiting)
3.	Certain situations because of a fear of particular objects or activities (e.g. animals, heights, seeing blood, being in confined spaces, driving or flying)

Work and Social Adjustment Scale

People'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 indicate how much your problem impairs your ability to carry out the activity.
Please choose a number and enter it in the box opposite.

Nil
Slightly
Definitely
Markedly
Severely

Task		Score
1.	WORK - if you are retired or choose not to have a job for reasons unrelated to your problem, please leave this blank.
2.	HOME MANAGEMENT - Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc.
3.	SOCIAL LEISURE ACTIVITIES - With other people, e.g. parties, pubs, outings, entertaining etc.
4.	PRIVATE LEISURE ACTIVITIES - Done alone, e.g. reading, gardening, sewing, hobbies, walking etc.
5.	FAMILY AND RELATIONSHIPS - Form and maintain close relationships with others, including the people that I live with.

Demographic Information

The following demographic information is requested so that we can make sure italk is reaching all sections of the community

Employment StatusPlease indicate which of the following options best describes your current status: