Baseline Information Questionnaire

DATE OF COMPLETION : / NAME:
DOB:

SECTION 1

We would like to start by asking you about how you generally are in most situations:

In general: / Yes / No
1 / Do you have difficulty making and keeping friends?
2 / Would you normally describe yourself as a loner?
3 / In general, do you have difficulties trusting other people?
4 / Do you normally lose your temper easily?
5 / Are you normally an impulsive sort of person?
6 / Are you normally a worrier?
7 / In general are you a perfectionist?
8 / In general, do you depend on others a lot?
9 / Do you think there is anything about your personality, that is to say the way you generally are, that needs to be changed?

SECTION 2

We would now like to ask your use of other services in the past 6 months – if this is hard to remember, perhaps you could guess!

In the past 6 months: / No / Once / 2 or 3 times / More than 3 times
1 / Did you make a routine (non-emergency) appointment to see your GP?
2 / Did you make an emergency appointment to see your GP?
3 / Did you attend an Accident and Emergency Department?
4 / Did you have an admission to hospital?
5 / Have you see a social worker, benefits or housing worker?
6 / Did you have contact with the Police?
7 / Were you arrested?
8 / Were you charged with an offence?
1 / Not at all unwell
2 / Very mildly unwell
3 / Mildly unwell
4 / Moderately unwell
5 / Markedly unwell
6 / Severely unwell
7 / Among the most extremely unwell

SECTION 3

How mentally unwell do you think you are at this time?

(Please put a tick in the box beside the item which you think describes you best at this time)

SECTION 4

On a scale from 1 to 100, how would you rate your current quality of life (where 100 represents best possible quality of life and 1 represents worst possible quality of life)?

I would rate my current quality of life as ...... out of 100

1 / Extremely unhopeful
2 / Very unhopeful
3 / Unhopeful
4 / Neither hopeful nor unhopeful
5 / Hopeful
6 / Very hopeful
7 / Extremely hopeful

SECTION 5

How hopeful are you that things will improve?

(Please put a tick in the box beside the item which you think describes you best at this time)

SECTION 6

Please consider the statements below and for each one, please circle the response which best fits your experience during the last six months?

1 / I complete my tasks at work and home satisfactorily (please circle the most appropriate):
Most of the time / Quite often / Sometimes / Not at all
2 / I find my tasks at work and at home very stressful (please circle the most appropriate):
Not at all / Sometimes / Quite often / Most of the time
3 / I have no money problems (please circle the most appropriate):
No problems at all / Slight worries only / Definite problems / Very severe problems
4 / I have difficulties in getting and keeping close relationships (please circle the most appropriate):
No problems at all / Occasional problems / Some problems / Severe difficulties
5 / I have problems in my sex life (please circle the most appropriate):
No problems at all / Occasional problems / Moderate problems / Severe difficulties
6 / I get on well with my family and other relatives (please circle the most appropriate):
Yes definitely / Yes usually / No, some problems / No, severe problems
7 / I feel lonely and isolated from other people (please circle the most appropriate):
Not at all / Not usually / Much of the time / Almost all the time
8 / I enjoy my spare time (please circle the most appropriate):
Very much / Sometimes / Not often / Not at all
9 / I generally have difficulties getting on with people (please circle the most appropriate):
Not at all / Not often / Sometimes / Very much
1 / Very much worse
2 / Much worse
3 / Slightly worse
4 / About the same
5 / Slightly better
6 / Much better
7 / Very much better

SECTION 7

Compared with how you were when you started treatment, how would you describe yourself now?

(Please put a tick in the box beside the item which you think describes you best at this time)

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