• As part of your assessment with Veterans' NHS Wales, there are some self-report measures for you to complete. These measures help your assessing therapist understand your current situation and how your symptoms affect you.

    The measures are for symptoms associated with trauma, depression, anxiety and insomnia. There is also a measure for alcohol use, general health and adverse childhood experiences.

    If you are not accessing Veterans' NHS Wales for treatment for a traumatic experience, then you will be able to skip the questionnaires which relate to trauma.

  • Have you experienced a traumatic event?*

  • International Trauma Questionnaire (ITQ)

  • Instructions: Please identify the experience that troubles you the most and answer the questions in relation to this experience.

  • When did the experience occur?*

  • Below are a number of problems that people sometimes report in response to a traumatic or stressful life events. Please read each item carefully, then select the option that indicates how much you have been bothered by that problem in the past month.

  • P1. Having upsetting dreams that replay part of the experience or are clearly related to the experience?*
  • P2. Having powerful images or memories that sometimes come into your mind in which you feel the experience is happening again in the here and now?*
  • P3. Avoiding internal reminders of the experience (for example, thoughts, feelings, or physical sensations)?*
  • P4. Avoiding external reminders of the experience (for example, people, places, conversations, objects, activities or situations)?*
  • P5. Being "super-alert", watchful, or on guard?*
  • P6. Feeling jumpy or easily startled?*

  • In the past month have the above problems:

  • P7. Affected your relationships or social life?*
  • P8. Affected your work or ability to work?*
  • P9. Affected any other important part of your life such as parenting, or school or college work, or other important activities?*

  • Below are problems that people who have had stressful or traumatic events sometimes experience. The questions refer to ways you typically feel, ways you typically think about yourself and ways you typically relate to others. Answer the following thinking about how true each statement is of you.

  • C1. When I am upset, it takes me a long time to calm down.*
  • C2. I feel numb or emotionally shut down.*
  • C3. I feel like a failure.*
  • C4. I feel worthless.*
  • C5. I feel distant or cut off from people.*
  • C6. I find it hard to stay emotionally close to people.*

  • In the past month, have the above problems in emotions, in beliefs about yourself and in relationships:

  • C7. Created concern or distress about your relationships or social life?*
  • C8. Affected your work or ability to work?*
  • C9. Affected any other important parts of your life such as parenting, or school or college work, or other important activities?*

  • PCL-5

  • Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Keeping your worst experience in mind, please read each problem carefully and then select one of the options to indicate how much you have been bothered by that problem in the past week. Note: Please answer the questions using the same experience as the previous trauma questionnaire.

  • 1. Repeated, disturbing, and unwanted memories of the stressful experience?*
  • 2. Repeated, disturbing dreams of the stressful experience?*
  • 3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?*
  • 4. Feeling very upset when something reminded you of the stressful experience?*
  • 5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*
  • 6. Avoiding memories, thoughts, or feelings related to the stressful experience?*
  • 7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?*
  • 8. Trouble remembering important parts of the stressful experience?*
  • 9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?*
  • 10. Blaming yourself or someone else strongly for the stressful experience or what happened after it?*
  • 11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?*
  • 12. Loss of interest in activities that you used to enjoy?*
  • 13. Feeling distant or cut off from other people?*
  • 14. Having trouble experiencing positive feelings (for example, being unable to have loving feelings for people close to you, or feeling emotionally numb)?*
  • 15. Feeling irritable or angry or acting aggressively?*
  • 16. Taking too many risks or doing things that cause you harm?*
  • 17. Being “superalert” or watchful or on guard?*
  • 18. Feeling jumpy or easily startled?*
  • 19. Having difficulty concentrating?*
  • 20. Trouble falling or staying asleep?*

  • PHQ-9

    Over the last 2 weeks, how often have you been bothered by any of the following problems?Please select an option to indicate your answer.
  • 1. Little interest or pleasure in doing things*
  • 2. Feeling down, depressed, or hopeless*
  • 3. Trouble falling or staying asleep, or sleeping too much*
  • 4. Feeling tired or having little energy*
  • 5. Poor appetite or over eating*
  • 6. Feeling bad about yourself- or that you are a failure or have let yourself or your family down*
  • 7. Trouble concentrating on things, such as reading the newspaper or watching television*
  • 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*
  • 9. Thoughts that you would be better off dead or of hurting yourself in some way*
  • If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?

  • GAD-7 Anxiety

    Over the last 2 weeks, how often have you been bothered by the following problems? Please select an option to indicate your answer. 
  • 1. Feeling nervous, anxious or on edge*
  • 2. Not being able to stop or control worrying*
  • 3. Worrying too much about different things*
  • 4. Trouble relaxing*
  • 5. Being so restless that it is hard to sit still*
  • 6. Becoming easily annoyed or irritable*
  • 7. Feeling afraid as if something awful might happen*
  • If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?*

  • Alcohol Screen

    How risky is your drinking?

  • Alcohol use can affect your health and interfere with certain medications and treatments. Answer the 10 questions below to find out how risky your drinking is. First check out the standard drink charts below.

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  • Image field 95

  • The charts above contain examples of one standard drink.

    A full strength can or stubbie contains one and a half standard drinks.

  • Select from the answers below. Try to answer the questions in terms of "standard drinks".

  • 1. How often do you have a drink containing alcohol?*
  • 2. How many standard drinks do you have on a typical day when you are drinking?*
  • 3. How often do you have six or more standard drinks on one occasion?*
  • 4. How often during the last year have you found that you were not able to stop drinking once you had started?*
  • 5. How often during the last year have you failed to do what was normally expected of you because of drinking?*
  • 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?*
  • 7. How often during the last year have you had a feeling of guilt or remorse after drinking?*
  • 8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?*
  • 9. Have you or someone else been injured because of your drinking?*
  • 10. Has a relative, friend, doctor or another health worker been concerned about your drinking or suggested you cut down?*

  • The full list of guidlines, risks and tips on changing your dinking are available from your assessing therapist.

  • 0 to 7Low risk - but...Check out the guidlines and additional risks to get the right mix.
    8 to 15Risky - your drinking has potential to cause harm...Consider low risk drinking, your diet and exercise. Try the tips for change.
    16 and aboveHigh Risk - likely that you are damaging your health or having problems...Seriously consider changing your drinking. Talk to your doctor or health professional.

     

  • Insomnia Severity Index

  • For each question, please select the option that best describes your answer.

     

    Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s).

  • 1. Difficulty falling asleep*
  • 2. Difficulty staying asleep*
  • 3. Problem waking up too early*
  • 4. How SATISFIED / DISSATISFIED are you with your CURRENT sleep pattern?*
  • 5. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?*
  • 6. How WORRIED / DISTRESSED are you about your current sleep problem?*
  • 7. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work / daily chores, concentration, memory, mood, etc.) CURRENTLY?*

  • EQ-5D

    To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer), on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0. We would like you to indicate on this scale how good or bad your own health is today, in your opinion.

  • Adverse Childhood Experience Questionnaire

  • This quesionnaire asks 14 questions about your childhood. Please select an option to indicate your answer.

  • 1. While you were growing up, before the age of 18 years, did you live with anyone who was depressed, mentally ill or suicidal?*
  • 2. While you were growing up, before the age of 18 years, did you live with anyone who was a problem drinker or alcoholic?*
  • 3. While you were growing up, before the age of 18 years, did you live with anyone who used illegal street drugs or who abused prescription medications?*
  • 4. While you were growing up, before the age of 18 years, did you live with anyone who served time or was sentenced to serve time in a prison or young offenders institution?*
  • 5. While you were growing up, before the age of 18 years, were your parents ever separated or divorced?*
  • 6. While you were growing up, before the age of 18 years, how often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up?*
  • 7. While you were growing up, before the age of 18 years, how often did a parent or adult in your home ever hit, beat, kick or physically hurt you in anyway? This does not include gentle smacking for punishment.*
  • 8. While you were growing up, before the age of 18 years, how often did a parent or adult in your home ever swear at you, insult you, or put you down?*
  • 9. While you were growing up, before the age of 18 years, how often did anyone at least 5 years older than you (including adults) ever touch you sexually?*
  • 10. While you were growing up, before the age of 18 years, how often did anyone at least 5 years older than you (including adults) try to make you touch them sexually?*
  • 11. While you were growing up, before the age of 18 years, how often did anyone at least 5 years older than you (including adults) force you to have any type of sexual intercourse (oral, anal or vaginal)?*
  • 12. While you were growing up, before the age of 18 years, did your parent/caregiver for long periods of time not provide you with enough food or drink, clean clothes or a clean and warm place to live when they could have?*
  • 13. While you were growing up, before the age of 18 years, were there times when there was no adult living with you who made you feel loved?*
  • 14. While you were growing up, before the age of 18 years, was there an adult in your life who you could trust and talk to about any personal problems?*

  • Thank you for completing the self-report measures for your assessment. Please click on the submit button to send your form to Veterans' NHS Wales.

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