18+ / Self / Follow-up | TRACK CLINIC

For each item, please mark the box for Not True, Somewhat True or Certainly True. It would help us if you answered all itemsas best you can even if you are not absolutely certain. Please give your answers on the basis of how things have been for you over the last month.

Full Name

Sex

Male

Female

Date of Birth

I try to be nice to other people. I care about their feelings

Not True

Somewhat True

Certainly True

I am restless, I find it hard to sit down for long

Not True

Somewhat True

Certainly True

I get a lot of headaches, stomach-aches or sickness

Not True

Somewhat True

Certainly True

I usually share with others, for example food or drink

Not True

Somewhat True

Certainly True

I get very angry and often lose my temper

Not True

Somewhat True

Certainly True

I would rather be alone than with other people

Not True

Somewhat True

Certainly True

I am generally willing to do what other people want

Not True

Somewhat True

Certainly True

I worry a lot

Not True

Somewhat True

Certainly True

I am helpful if someone is hurt, upset or feeling ill

Not True

Somewhat True

Certainly True

I am constantly fidgeting or squirming

Not True

Somewhat True

Certainly True

I have at least one good friend

Not True

Somewhat True

Certainly True

I fight a lot. I can make other people do what I want

Not True

Somewhat True

Certainly True

I am often unhappy, depressed or tearful

Not True

Somewhat True

Certainly True

Other people generally like me

Not True

Somewhat True

Certainly True

I am easily distracted, I find it difficult to concentrate

Not True

Somewhat True

Certainly True

I am nervous in new situations. I easily lose confidence

Not True

Somewhat True

Certainly True

I am kind to children

Not True

Somewhat True

Certainly True

I am often accused of lying or cheating

Not True

Somewhat True

Certainly True

Other people pick on me or bully me

Not True

Somewhat True

Certainly True

I often offer to help others (family members, friends, colleagues)

Not True

Somewhat True

Certainly True

I think before I do things

Not True

Somewhat True

Certainly True

I take things that are not mine from home, work or elsewhere

Not True

Somewhat True

Certainly True

I get along better with older people than with people of my own age

Not True

Somewhat True

Certainly True

I have many fears, I am easily scared

Not True

Somewhat True

Certainly True

I finish the work I'm doing. My attention is good

Not True

Somewhat True

Certainly True

Do you have any other comments or concerns?

Since coming to the clinic, are your problems:

Has coming to the clinic been helpful in other ways, e.g. providing information or making the problems more bearable?

Not at all

Only a little

Quite a lot

A great deal

Over the last month, have you had difficulties in one or more of the following areas: emotions, concentration, behaviour or being able to get on with other people?

No

Yes - minor difficulties

Yes - definite difficulties

Yes - severe difficulties

Do the difficulties upset or distress you?

Not at all

Only a little

Quite a lot

A great deal

Do the difficulties interfere with your everyday life in getting along with the people you are closest to (e.g. family, partner)?

Not at all

Only a little

Quite a lot

A great deal

Do the difficulties interfere with your everyday life in making and keeping friends?

Not at all

Only a little

Quite a lot

A great deal

Do the difficulties interfere with your everyday life in work or study?

Not at all

Only a little

Quite a lot

A great deal

Do the difficulties interfere with your everyday life in your hobbies, sports or other leisure activities?

Not at all

Only a little

Quite a lot

A great deal

Do the difficulties make it harder for those around you (family, friends, etc.)?

Not at all

Only a little

Quite a lot

A great deal

Signature

Follow-up SDQ

Self-Assessment (over 18)

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