Mental Health Questionnaire Pre-course

Mental Health Questionnaire Pre-course
Please complete this form before the start of the first swimming session
Name*
First Last

Over the last 2 weeks, how often have you been bothered by any of the following problems?*

	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

GAD7

Over the last 2 weeks, how often have you been bothered by any of the following problems?*

	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself — or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
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
Thoughts that you would be better off dead or of hurting yourself in some way

PHQ 9

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 determine on the scale provided how much your problem impairs your ability to carry out the activity.
WORK – if you are retired or choose not to have a job for reasons unrelated to your problem, please tick N/A (not applicable)*
Not at all (0) 1 Slightly (2) 3 Definitely (4) 5 Markedly (6) 7 Very Severely (8) N/A
HOME MANAGEMENT – Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc*
Not at all (0) 1 Slightly (2) 3 Definitely (4) 5 Markedly (6) 7 Very Severely (8) N/A
SOCIAL LEISURE ACTIVITIES – With other people, e.g. parties, pubs, outings, entertaining etc.*
Not at all (0) 1 Slightly (2) 3 Definitely (4) 5 Markedly (6) 7 Very Severely (8) N/A
PRIVATE LEISURE ACTIVITIES – Done alone, e.g. reading, gardening, sewing, hobbies, walking etc.*
Not at all (0) 1 Slightly (2) 3 Definitely (4) 5 Markedly (6) 7 Very Severely (8) N/A
FAMILY AND RELATIONSHIPS – Form and maintain close relationships with others including the people that I live with*
Not at all (0) 1 Slightly (2) 3 Definitely (4) 5 Markedly (6) 7 Very Severely (8) N/A