Adult information questionnaire

Adult information questionnaire
 
1=Not a Problem‚ 2=Somewhat of a Problem‚ 3=A Moderate Problem‚ 4=A Serious Problem‚ 5=A Severe Problem
I YOUR PHYSICAL FUNCTIONS
1.    Sleep Pattern
2.    Eating Pattern
3.    Bladder Control
4.    Bowel Control
5.    Seizures or Convulsions
6.    Speech (stuttering or stammering)
7.    Weight Problems
8.    Sexual Functioning
9.    Other:
II YOUR EXPERIENCE AT WORK
10.General Performance
11.General Satisfaction
12. Lateness
13.Absenteeism
14.14 Negative Feelings About Work
15.Relating to Supervisors
16.Relating to Co-Workers
17.Relating to Supervisees
18.Other:
III YOUR BEHAVIOR
19.difficulty with Daily routine
20.Letting Others Take Advantage of You
21.Hyperactivity (can't sit still)
22. Repeating Certain Acts‚  Again and Again
23.Physically Abusing Others
24. Using Alcohol to Cope with Problems
25. Using Drugs to Cope with Problems 
26. Lying
27. Stealing 
28. Withdrawal from Others Socially
29. Dependency (relying on others to make your decisions and take care of you)
30.Suspiciousness (questioning other people's motives)
31. Hostility (feeling angry towards others)
32.Other:
IV YOUR FEELINGS & MOOD
33.Depression (sadness)
34.Euphoria (feeling "high")
35. Sudden Changes in Mood for No Apparent Reason
36. Anxiety
37. Lack of Energy
38. Feeling Angry
39.Not Liking Self
40.Not Liking Others
41.Other:
V YOUR INNER THOUGHTS & IDEAS
42.Thoughts About Hurting Yourself
43. ha‎ving Unwanted Thoughts Again and Again
44. Worrying About Your Health
45.Believing You are Inferior to Others
46. Believing You are Better than Others
47. Seeing Things without Apparent Cause
48. Hearing Things without Apparent Cause
49. Experiencing Confusion
50. Memory
51. Other:
VI YOUR OTHER DIFFICULTIES
(Please feel free to add any items not previously noted)
52. 
53. 
54. 
PRE _________  POST ___________
 
This instrument can be found online at: http://balancedchoices.net/
For more information: USA: 704-655-2827; Ireland: 064 6634513
Balanced Choices has locations in Davidson‚ NC USA and Southwest Ireland