Personal Information:
    Your Name:
    Your Email:
    Your Phone:
    Age (Years):

    Please read this carefully. We should like to know if you have had any medical complaints and how your health has been in general, over the past few weeks. Please answer ALL the questions on the following pages simply by underlining the answer which you think most nearly applies to you. Remember that we want to know about present and recent complaints, not those that you had in the past. It is important that you try to answer ALL the questions. Thank you very much for your co-operation.

    "Section-A"

    Have you recently?

     A1 - been feeling perfectly well and in good health? A2 - been feeling in need of a good tonic? A3 - been feeling run down and out of sorts? A4 - felt that you are ill? A5 - been getting any pains in your head? A6 - been getting a feeling of tightness or pressure in your head? A7 - been having hot or cold spells?

    "Section-B"

     B1 - lost much sleep over worry? B2 - had difficulty in staying asleep more once you are off? B3 - felt constantly under strain? B4 - been getting edgy and bad-tempered? B5 - been getting scared or panicky for no good reason? B6 - found everything getting on top of you? B7 - been feeling nervous and strung-up all the time?

    "Section-C"

     C1 - been managing to keep yourself busy and occupied? C2 - been taking longer over the things you do? C3 - felt on the whole you were doing things well? C4 - been satisfied with the way you've carried out your task? C5 - felt that you are playing a useful part in things? C6 - felt capable of making decisions about things? C7 - been able to enjoy your normal day-to-day activities?

    "Section-D"

     D1 - been thinking of yourself as a worthless person? D2 - felt that life is entirely hopeless? D3 - felt that life isn't worth living? D4 - thought of the possibility that you might make away with yourself? D5 - found at times you couldn't do anything because your nerves were too bad? D6 - found yourself wishing you were dead and away from it all? D7 - found that the idea of taking your own life kept coming into your mind?