Pre Intervention Evaluation Form

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Pre Intervention Evaluation Form

April 14 - June 16, 2020

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Personal code (last 2 digits of birth year) (last 2 letters of last name) (first 2 digits of phone #) *

Please rate each of the following statements using the scale provided. Click the choice that best describes your own opinion of what is generally true for you.

1. I’m good at finding the words to describe my feelings. *

1 - Never or very rarely true

2 - Not often true

3 - Sometimes true sometimes not true

4 - Often true

5 - Very often or always true

2. When I take a shower or a bath, I stay alert to the sensations of water on my body. *

1 - Never or very rarely true

2 - Not often true

3 - Sometimes true sometimes not true

4 - Often true

5 - Very often or always true

3. I don't pay attention to what I'm doing because I'm daydreaming, worrying, or otherwise distracted. *

1 - Never or very rarely true

2 - Not often true

3 - Sometimes true sometimes not true

4 - Often true

5 - Very often or always true

4. I believe some of my thoughts are abnormal or bad and I shouldn't think that way. *

1 - Never or very rarely true

2 - Not often true

3 - Sometimes true sometimes not true

4 - Often true

5 - Very often or always true

5. When I have distressing thoughts or images, I 'step back' and am aware of the thought or image without getting taken over by it. *

1 - Never or very rarely true

2 - Not often true

3 - Sometimes true sometimes not true

4 - Often true

5 - Very often or always true

6. I notice how foods and drinks affect my thoughts, bodily sensations, and emotions. *

1 - Never or very rarely true

2 - Not often true

3 - Sometimes true sometimes not true

4 - Often true

5 - Very often or always true

7. I have trouble thinking of the right words to express how I feel about things. *

1 - Never or very rarely true

2 - Not often true

3 - Sometimes true sometimes not true

4 - Often true

5 - Very often or always true

8. I do jobs or tasks automatically without being aware of what I'm doing. *

1 - Never or very rarely true

2 - Not often true

3 - Sometimes true sometimes not true

4 - Often true

5 - Very often or always true

9. I think some of my emotions are bad or inappropriate and I shouldn't feel them. *

1 - Never or very rarely true

2 - Not often true

3 - Sometimes true sometimes not true

4 - Often true

5 - Very often or always true

10. When I have distressing thoughts or images I am able to just notice them without reacting. *

1 - Never or very rarely true

2 - Not often true

3 - Sometimes true sometimes not true

4 - Often true

5 - Very often or always true

11. I pay attention to sensations, such as the wind in my hair or sun on my face. *

1 - Never or very rarely true

2 - Not often true

3 - Sometimes true sometimes not true

4 - Often true

5 - Very often or always true

12. Even when I'm feeling terribly upset I can find a way to put it into words. *

1 - Never or very rarely true

2 - Not often true

3 - Sometimes true sometimes not true

4 - Often true

5 - Very often or always true

13. I find myself doing things without paying attention. *

1 - Never or very rarely true

2 - Not often true

3 - Sometimes true sometimes not true

4 - Often true

5 - Very often or always true

14. I tell myself I shouldn't be feeling the way I'm feeling. *

1 - Never or very rarely true

2 - Not often true

3 - Sometimes true sometimes not true

4 - Often true

5 - Very often or always true

15. When I have distressing thoughts or images I just notice them and let them go. *

1 - Never or very rarely true

2 - Not often true

3 - Sometimes true sometimes not true

4 - Often true

5 - Very often or always true

Over the last 2 months, how often have you been bothered by the following problems?

16. Feeling nervous anxious, or on edge *

1 - Not at all

2 - Several days

3 - Over half the days

4 - Nearly every day

17. Not being able to stop or control worrying *

1 - Not at all

2 - Several days

3 - Over half the days

4 - Nearly every day

18. Worrying too much about different things *

1 - Not at all

2 - Several days

3 - Over half the days

4 - Nearly every day

19. Trouble relaxing *

1 - Not at all

2 - Several days

3 - Over half the days

4 - Nearly every day

20. Being so restless that it’s hard to sit still *

1 - Not at all

2 - Several days

3 - Over half the days

4 - Nearly every day

21. Becoming easily annoyed or irritable *

1 - Not at all

2 - Several days

3 - Over half the days

4 - Nearly every day

22. Feeling afraid as if something awful might happen *

1 - Not at all

2 - Several days

3 - Over half the days

4 - Nearly every day

Please indicate for each of the five statements which is closes to how you have been feeling over the last two months.

23. I have felt cheerful and in good spirits *

1 - Never

2 - Not often

3 - Sometimes

4 - Often

5 - All of the time

24. I have felt calm and relaxed *

1 - Never

2 - Not often

3 - Sometimes

4 - Often

5 - All of the time

25. I have felt active and vigorous *

1 - Never

2 - Not often

3 - Sometimes

4 - Often

5 - All of the time

26. I woke up feeling fresh and rested *

1 - Never

2 - Not often

3 - Sometimes

4 - Often

5 - All of the time

27. My daily life has been filled with things that interest me *

1 - Never

2 - Not often

3 - Sometimes

4 - Often

5 - All of the time

Below is a list of some of the ways you may have felt or behaved in the last two months. Please indicate how often you have felt this way by checking the appropriate space.

28. I did not feel like eating; my appetite was poor *

1 - Rarely or none of the time

2 - Some or a little of the time

3 - Occasionally or a moderate amount of the time

4 - Most or all of the time

29. I felt depressed *

1 - Rarely or none of the time

2 - Some or a little of the time

3 - Occasionally or a moderate amount of the time

4 - Most or all of the time

30. I felt everything I did was an effort *

1 - Rarely or none of the time

2 - Some or a little of the time

3 - Occasionally or a moderate amount of the time

4 - Most or all of the time

31. My sleep was restless *

1 - Rarely or none of the time

2 - Some or a little of the time

3 - Occasionally or a moderate amount of the time

4 - Most or all of the time

32. I was happy *

1 - Rarely or none of the time

2 - Some or a little of the time

3 - Occasionally or a moderate amount of the time

4 - Most or all of the time

33. I felt lonely *

1 - Rarely or none of the time

2 - Some or a little of the time

3 - Occasionally or a moderate amount of the time

4 - Most or all of the time

34. People were unfriendly *

1 - Rarely or none of the time

2 - Some or a little of the time

3 - Occasionally or a moderate amount of the time

4 - Most or all of the time

35. I enjoyed life *

1 - Rarely or none of the time

2 - Some or a little of the time

3 - Occasionally or a moderate amount of the time

4 - Most or all of the time

36. I felt sad *

1 - Rarely or none of the time

2 - Some or a little of the time

3 - Occasionally or a moderate amount of the time

4 - Most or all of the time

37. I felt that people disliked me *

1 - Rarely or none of the time

2 - Some or a little of the time

3 - Occasionally or a moderate amount of the time

4 - Most or all of the time

38. I could not get “going” *

1 - Rarely or none of the time

2 - Some or a little of the time

3 - Occasionally or a moderate amount of the time

4 - Most or all of the time

Thank you!

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