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Pre-Program Questionnaire
W4W Participants will complete this questionnaire prior to engaging in their first clinic day.
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Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things.
Not at all
1
2
3
4
Nearly every day
Clear selection
Feeling down, depressed, or hopeless.
Not at all
1
2
3
4
Nearly every day
Clear selection
Trouble falling or staying asleep, or sleeping too much.
Not at all
1
2
3
4
Nearly every day
Clear selection
Feeling tired or having little energy.
Not at all
1
2
3
4
Nearly every day
Clear selection
Poor appetite or over eating.
Not at all
1
2
3
4
Nearly every day
Clear selection
Feeling bad about yourself, or that you are a failure and have let yourself or your family down.
Not at all
1
2
3
4
Nearly every day
Clear selection
Trouble concentrating on things such as reading the newspaper or watching television.
Not at all
1
2
3
4
Nearly every day
Clear selection
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.
Not at all
1
2
3
4
Nearly every day
Clear selection
Thoughts that you would be better off dead or hurting yourself in some way.
Not at all
1
2
3
4
Nearly every day
Clear selection
Feeling nervous, anxious, or on edge.
Not at all
1
2
3
4
Nearly every day
Clear selection
Not being able to stop or control worrying.
Not at all
1
2
3
4
Nearly every day
Clear selection
Worrying too much about different things.
Not at all
1
2
3
4
Nearly every day
Clear selection
Trouble relaxing.
Not at all
1
2
3
4
Nearly every day
Clear selection
Being so restless that it is hard to sit still.
Not at all
1
2
3
4
Nearly every day
Clear selection
Becoming easily annoyed or irritable.
Not at all
1
2
3
4
Nearly every day
Clear selection
Feeling afraid as if something awful might happen.
Not at all
1
2
3
4
Nearly every day
Clear selection
Please rate your current level of comfortability with the ocean.
Not comfortable
1
2
3
4
Extremely comfortable
Clear selection
Do you currently use tools including mindfulness and having a growth mindset in your day-to day life?
Never
Occasionally
Frequently
All the time
Clear selection
Next
Clear form
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