Looking after your mental health and wellbeing

Name *

Date *

Your mood

Over the last two weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things *

0 - Not at all 1 - Several days 2 - Over half the days 3 - Nearly every day

Feeling down, depressed or hopeless *

0 - Not at all 1 - Several days 2 - Over half the days 3 - Nearly every day

Trouble falling asleep or staying asleep, or sleeping too much *

0 - Not at all 1 - Several days 2 - Over half the days 3 - Nearly every day

Feeling tired or having little energy *

0 - Not at all 1 - Several days 2 - Over half the days 3 - Nearly every day

Poor appetite or overeating. *

0 - Not at all 1 - Several days 2 - Over half the days 3 - Nearly every day

Feeling bad about yourself Ã¢ÂÂ or that you are a failure or have let yourself or your family down. *

0 - Not at all 1 - Several days 2 - Over half the days 3 - Nearly every day

Trouble concentrating on things such as reading the newspaper or watching television. *

0 - Not at all 1 - Several days 2 - Over half the days 3 - Nearly every day

Moving or speaking so slowly that other people have noticed. Or the opposite Ã¢ÂÂ being so fidgety or restless that you have been moving around a lot more than usual. *

0 - Not at all 1 - Several days 2 - Over half the days 3 - Nearly every day

Thoughts that you would be better off dead or of hurting yourself in some way. *

0 - Not at all 1 - Several days 2 - Over half the days 3 - Nearly every day

If you have had any of these problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all Somewhat difficult Very difficult Extremely difficult

Over the last two weeks, how often have you been bothered by the following problems?

Feeling nervous anxious or on edge *

0 - Not at all 1 - Several days 2 - Over half the days 3 - Nearly every day

Not being able to stop or control worrying *

0 - Not at all 1 - Several days 2 - Over half the days 3 - Nearly every day

Worrying too much about different things *

0 - Not at all 1 - Several days 2 - Over half the days 3 - Nearly every day

Trouble relaxing *

0 - Not at all 1 - Several days 2 - Over half the days 3 - Nearly every day

Being so restless that it's hard to sit still *

Not at all Several days Over half the days Nearly every day

Becoming easily annoyed or irritable *

0 - Not at all 1 - Several days 2 - Over half the days 3 - Nearly every day

Feeling afraid as if something awful might happen *

0 - Not at all 1 - Several days 2 - Over half the days 3 - Nearly every day

If you have had any of these problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all Somewhat difficult Very difficult Extremely difficult

Your drug use

Which, if any, of these drugs have you used during the last year, and how often do you use them?

Cannabis, hash

Less than three times/year Once a month More than once a month Once a week Three times a Week Everyday

Cocaine

Less than three times/year Once a month More than once a month Once a week Three times a Week Everyday

Crack, freebase

Less than three times/year Once a month More than once a month Once a week Three times a Week Everyday

Heroin

Less than three times/year Once a month More than once a month Once a week Three times a Week Everyday

Methadone (without a prescription or more than a doctor told you too)

Less than three times/year Once a month More than once a month Once a week Three times a Week Everyday

Sedatives/tranquilizers/downers (without a prescription or more than a doctor told you to)

Less than three times/year Once a month More than once a month Once a week Three times a Week Everyday

Speed/crystal meth/uppers

Less than three times/year Once a month More than once a month Once a week Three times a Week Everyday

Ecstasy, MDMA, M-CAT

Less than three times/year Once a month More than once a month Once a week Three times a Week Everyday

LSD, magic mushrooms, hallucinogens

Less than three times/year Once a month More than once a month Once a week Three times a Week Everyday

GHB/GBL

Less than three times/year Once a month More than once a month Once a week Three times a Week Everyday

Ketamine

Less than three times/year Once a month More than once a month Once a week Three times a Week Everyday

Legal highs

Less than three times/year Once a month More than once a month Once a week Three times a Week Everyday

I don't use any of the drugs above

Please tick here

Have you ever injected any drugs with a needle ('slammed') ? *

Yes No

If 'yes', has this happened during the last six months?

Yes No

Do you smoke? *

Your alcohol use

How often do you have a drink containing alcohol?

0 - Never 1 - Monthly or less 2 - 2-4 times per month 3 - 2-3 times per week 4- 4 or more times per week

How many units of alcohol do you drink on a typical day when you are drinking?

1-2 3-4 5-6 7-9 10+

How often have you had six or more units if female, or eight or more if male, on a single occasion in the last year?

Never Monthly or less 2-4 times per month 2-3 times per week 4 or more times per week

Alcohol unit guide

Your memory

Do you experience frequent memory loss (e.g. do you forget the occurrence of special events even the more recent ones, appointments, etc.)? *

Do you feel that you are slower when reasoning, planning activities, or solving problems? *

Do you have difficulties paying attention (e.g. to a conversation, a book, or a movie)? *

Looking after your mental health and wellbeing

Your mental health and well-being is important. Please answer these questions as honestly as possible. Your answers will only be viewed by the clinician seeing you at your next appointment.

Please complete this confidential questionnaire prior to your appointment. Thank you.

Your mood

Over the last two weeks, how often have you been bothered by the following problems?

Over the last two weeks, how often have you been bothered by the following problems?

Your drug use

Which, if any, of these drugs have you used during the last year, and how often do you use them?

Your alcohol use

Alcohol unit guide

Your memory