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    Complete Application




    WHODAS 2.0:


    This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs.

    Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please circle only one response.

    In the past 30 days, how much difficulty did you have in:

    S1) Standing for long periods such as 30 minutes?

    S2) Taking care of your household responsibilities?

    S3) Learning a new task, for example, learning how to get to a new place?

    S4) How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?

    S5) How much have you been emotionally affected by your health problems?

    S6) Concentrating on doing something for ten minutes?

    S7) Walking a long distance such as a kilometre [or equivalent]?

    S8) Washing your whole body?

    S9) Getting dressed?

    S10) Dealing with people you do not know?

    S11) Maintaining a friendship?

    S12) Your day-to-day work?

    WHODAS 2.0 Total
    H1) Overall, in the past 30 days, how many days were these difficulties present?

    Record number of days
    H2) In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?

    Record number of days
    H3) In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?

    Record number of days


    PTSD PCL-5


    Instruction to patient: Below is a list of problems and complaints that veterans sometimes have in response to stressful life experiences. Please read each one carefully, click on the circle to indicate how much you have been bothered by that problem in the past week.

    1) Repeated, disturbing, and unwanted memories of the stressful experience?

    2) Repeated, disturbing dreams of the stressful experience?

    3) Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?

    4) Feeling very upset when something reminded you of the stressful experience?

    5) Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?

    6) Avoiding memories, thoughts, or feelings related to the stressful experience?

    7) Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?

    8) Trouble remembering important parts of the stressful experience?

    9) Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?

    10) Blaming yourself or someone else for the stressful experience or what happened after it?

    11) Having strong negative feelings such as fear, horror, anger, guilt, or shame?

    12) Loss of interest in activities that you used to enjoy?

    13) Feeling distant or cut off from other people?

    14) Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?

    15) Irritable behavior, angry outbursts, or acting aggressively?

    16) Taking too many risks or doing things that could cause you harm?

    17) Being “superalert” or watchful or on guard?

    18) Feeling jumpy or easily startled?

    19) Having difficulty concentrating?

    20) Trouble falling or staying asleep?

    PTSD PCL-5 Total


    PHQ-9


    Over the last 2 weeks, how often have you been bothered by any of the following problems?

    1. Little interest or pleasure in doing things

    2. Feeling down, depressed, or hopeless

    3. Trouble falling or staying asleep, or sleeping too much

    4. Feeling tired or having little energy

    5. Poor appetite or overeating

    6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down

    7. Trouble concentrating on things, such as reading the newspaper or watching television

    8. 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 more than usual

    9. Thoughts that you would be better off dead, or of hurting yourself in some way

    10. If you have checked off any of these problems, how difficult have these problems made it for you to do work, take care of things at home, or get along

    PHQ 9 Total


    GAD-7


    Over the last 2 weeks, how often have you been bothered by any of the following problems?

    1. Feeling nervous, anxious, or on edge

    2. Not being able to stop or control worrying

    3. Worry too much about different things

    4. Trouble Relaxing

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

    6. Becoming easily annoyed or irritable

    7. Feels afraid as if something awful might happen

    If you have checked off any of these problems, how difficult have these problems made it for you to do work, take care of things at home, or get along with people?


    WHODAS 2.0 Total
    PTSD PCL-5 Total
    PHQ-9 Total
    GAD-7 Total