NEXT AGM: THURS 27 JAN 2022: 6PM AEST
For all questions, please tick
the appropriate square
Initials:
Date:
QUESTION: In the past 4 weeks...
01 About How often do you feel tired out for no good reason?12345
02 About how often did you feel nervous?12345
03 About how often did you feel so nervous that nothing could calm you down?12345
04 About how often did you feel hopeless?12345
05 About how often did you feel restless or fidgety?12345
06 About how often did you feel so restless you could not sit still?12345
07 About how often did you feel depressed?12345
08 About how often did you feel that everything is an effort?12345
09 About how often did you feel so sad that nothing could cheer you up?12345
10 About how often did you feel worthless?12345
10-15 = Low Distress – No Help Required
16-19 = Mild Distress – Self Help
20-24 = Moderate Distress – Self Help
25-29 = Severe Distress – Some Support Required
30-50 = Extremely Severe Distress - Professional Help Required
0/50
No Satisfaction At all Completely Satisfied
0
1
2
3
4
5
6
7
8
9
10
1. How satisfied are you with your life as a whole? 12345678910
2. How satisfied are you with your standard of living? 12345678910
3. How satisfied are you with your health? 12345678910
4. How satisfied are you with what you are currently achieving in life? 12345678910
5. How satisfied are with your personal relationships? 12345678910
6. How satisfied are you with how safe you feel? 12345678910
7. How satisfied are you with feeling part of your community? 12345678910
8. How satisfied are you with your future security? 12345678910
TOTAL SCORE: 0
"1" if you Very Strongly Disagree
"2" if you Strongly Disagree
"3" if you Mildly Disagree
"4" if you are Neutral
"5" if you Mildly Agree
"6" if you Strongly Agree
"7" if you Very Strongly Agree
Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree
01 There is a special person who is around when I am in need.1234567
02 There is a special person with whom I can share joys and sorrows.1234567
03 My family really tries to help me.1234567
04 I get the emotional help & support I need from my family.1234567
05 I have a special person who is a real source of comfort to me.1234567
06 My friends really try to help me.1234567
07 I can count on my friends when things go wrong.1234567
08 I can talk about my problems with my family.1234567
09 I have friends with whom I can share my joys and sorrows.1234567
10 There is a special person in my life who cares about my feelings.1234567
11 My family is willing to help me make decisions.1234567
12 I can talk about my problems with my friends.1234567
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