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Internet Mental Health

SURNAME: SEX: MARITAL STATUS:

QUALITY OF LIFE SCALE
GIVEN NAME: AGE: [ ] DATE:

www.mentalhealth.com
MM DD YY

RESIDENTIAL STATUS: … Male … Never Married … Married … Female … Widowed … Divorced … Separated … In Other Institution

… In Hospital … At Home

OCCUPATION: … Employed … Homemaker

(N/A = Not Applicable) … Unemployed … Retired … Student … Disabled

MAJOR DEPRESSION HAS MOST OF THE ITEMS HIGHLIGHTED IN YELLOW
Vigorous Physical Exercise
1 Sweaty vigorous exercise (e.g., running, biking, tennis, hiking, or swimming) 0 A lot ( 3 hrs / wk of vigorous exercise ) 1 Some ( 1 hr / wk of vigorous exercise ) 2 Little ( less than 1 hr/wk of vigorous exercise)

Physical Mobility

2 E.g., walking, climbing stairs, standing, lifting, carrying and holding 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling; prevents work )

Pain or Discomfort
Physical pain or discomfort 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling; prevents work )

3

Fatigue

4 Feeling tired or having little energy 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling; prevents work )

Sleeping Problem
Sleeping much more or less than usual 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling; prevents work )

5

Appetite or Eating Problem

6 Eating much more or less than usual 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling; prevents work ) 9 Extent to which physical health problems interfere with usual activities 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling; prevents work ) Items 1-9 Subtotal:

Sexual Problems

7 E.g., uninterested in sex; unable to reach normal orgasm; painful sex 0 No or little difficulty … OR N/A 1 Much difficulty 2 Severe difficulty ( prevents sex )

Seeing or Hearing Problems
E.g., blindness, deafness 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling; prevents work ) (Please leave the subtotal boxes empty)

8

Overall Physical Health

Family Problems

10 E.g., death or illness of family member; family discord, neglect, or divorce 0 No or little difficulty … OR N/A 1 Much difficulty ( OR has little contact ) 2 Severe difficulty ( OR has no contact )

11 E.g., shyness, social anxiety, social isolation, rejection by others, loss of friend 0 No or little difficulty 1 Much difficulty ( OR has few close friends ) 2 Severe difficulty ( OR has no close friends )

Friendship Problems

Distrust or Suspiciousness
Distrust and suspiciousness of others

12

0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling; prevents work ) 15 E.g., unemployment; job dissatisfaction; poor job performance; social discord at work 0 No or little difficulty … OR N/A 3 Much difficulty ( OR works less than 8 hr/wk) 6 Severe difficulty ( OR not working )

Dependent Behavior

13 Over-reliance on others to meet emotional and physical needs 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling; prevents work ) Items 10-13 Subtotal:

Educational Problems

14 E.g., academic problems (when compared to peers); discord with teachers or classmates 0 No or little difficulty … OR N/A 1 Much difficulty ( OR failing school courses ) 2 Severe difficulty ( OR can’t read or write well)

Occupational Problems

Housekeeping Problems

16 E.g., problems cleaning, cooking, doing laundry, grocery shopping 0 No or little difficulty … OR N/A 3 Much difficulty ( OR does little housekeeping) 6 Severe difficulty ( OR not housekeeping )

17 E.g., inadequate finances; over-spending: reliant on government financial assistance 0 No or little difficulty … OR N/A 3 Much difficulty ( OR on financial assistance) 6 Severe difficulty

Economic Problems

Housing Problems
E.g., homelessness; inadequate housing; discord with neighbors or landlord 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( OR homeless ) Items 14-18 Subtotal:

18

Reckless Thrill-Seeking Behavior 19
Recklessly disregards danger thrill-seeking (dangerous gambling, sports, driving, or sex) 0 No or little difficulty 1 Much difficulty ( OR sometimes ) 2 Severe difficulty ( OR often )

Disrespect For The Law

20 Disrespect for normal law-abiding behavior 0 No or little difficulty 1 Much difficulty ( OR sometimes ) 2 Severe difficulty ( OR often )

Physical Violence
Physical violence towards others (e.g., physical assault or property damage) 0 No or little difficulty 1 Much difficulty ( OR sometimes ) 2 Severe difficulty ( OR often ) Items 19-21 Subtotal:

21

Smoking

22 Nicotine use (e.g., cigarettes, cigars, pipes) 0 None … OR N/A 1 Some ( but not chain smoking ) 2 A lot ( chain smoking )

23 Alcohol use causing harm to self or others 0 No or little difficulty … OR N/A 1 Much difficulty 2 Severe difficulty ( disabling; prevents work )

Alcohol Abuse

24 Drug use causing harm to self or others 0 No or little difficulty … OR N/A 1 Much difficulty ( OR ANY illegal drug use ) 2 Severe difficulty ( disabling; prevents work ) Items 22-24 Subtotal:
[Version Sept 27, 2009]

Drug or Medication Abuse

Copyright © 2004-2008 Phillip W. Long, M.D.

(Permission Granted For Non-commercial Reprinting + Use In Research)

or moving so slowly that it was noticeable to others 0 No or little difficulty 3 Much difficulty 6 Severe difficulty ( disabling. prevents work ) Generalized Worry 30 Prolonged.D. prevents work ) Other Phobia Panic Attacks 27 Sudden. or smells) 0 No or little difficulty 3 Much difficulty 6 Severe difficulty ( disabling.g. heights) 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling. prevents work ) Confusion Need for Institutional Care E. or worthless 32 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling. or hostility 31 Self-Blame Feeling guilty. can’t sit still. anger. importance. feeding self.g. prevents work ) Concentration or Attention 40 Difficulty concentrating on things (e. planning. M. knowledge. nursing home. 0 No or little difficulty ( oriented + alert ) 3 Much difficulty ( disoriented/ confused ) 6 Severe difficulty ( in a stupor or coma ) Items 40-48 Subtotal: Personal Self-Care 46 Difficulty with washing.g.. prevents work ) 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling. prevents work ) Obsessions or Compulsions 28 Unwanted obsessive thoughts or compulsive rituals DUE TO unreasonable fear or panic 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling..Agoraphobia 25 Unable to leave home alone DUE TO unreasonable intense fear or panic 0 No or little difficulty 3 Much difficulty 6 Severe difficulty ( disabling.g. ashamed. speaking. remembering appointments or to take medications 0 No or little difficulty 3 Much difficulty 6 Severe difficulty ( disabling. prevents work ) Item 36: Disorganized Speech or Bizarre Behavior 39 Speech is mixed up or incoherent. prevents work ) Grandiosity 37 Bizarrely inflated appraisal of one’s worth. visions. or identity 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling. power.g. prevents work ) Memory Executive Functioning 43 Impaired judgment. decreased spontaneous speech 0 No or little difficulty 3 Much difficulty 6 Severe difficulty ( disabling.. impatience. prevents work ) Items 37-39 Subtotal: 42 Difficulty learning new things. prevents work ) 26 Other unreasonable fear or panic DUE TO a specific situation (e. prevents work ) 48 Gets lost near home. doesn’t know the year.g. reading the newspaper or watching TV) 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling. brief attacks of unreasonable fear or panic NOT DUE TO a specific situation 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling. prevents work ) Anger Irritability.. lacks zest or motivation to do required daily activities) 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling. flying.. Long.g. excessive pacing or hand-wringing) 36 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling. or bizarre behavior (e. prevents work ) 33 Suicidal thoughts OR risk of harming self by self-injury or severe self-neglect 0 No or little difficulty 3 Much difficulty ( but self-harm isn’t imminent ) 6 Severe difficulty ( self-harm is imminent ) Items 29-33 Subtotal: Risk of Harming Self Elated Mood Feeling so happy or excited that it causes problems 34 Over-Talkative or Racing Speech 35 Overly talkative or speech races from topic to topic 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling. group home) or hospitalization 0 Is not in residential or hospital care 3 Is in ( non-hospital ) residential care 6 Is in hospital OR was recently discharged Item 49: Copyright © 2004-2008 Phillip W. 2009] (Permission Granted For Non-commercial Reprinting + Use In Research) . needs residential care (e. or body odor 0 No or little difficulty 3 Much difficulty 6 Severe difficulty ( unable to do self-care ) Psychomotor Slowing 47 Thinking. unreasonable intense fear or worry about a NUMBER of different things 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling. prevents work ) Items 25-28 Subtotal: Depressed or Hopeless Mood 29 Feeling down. 49 50 Understanding (and willingness to change) one’s own personal problems 0 No or little difficulty 3 Much difficulty ( OR partially refuses help ) 6 Severe difficulty ( OR refuses all help ) Item 50: Insight Overall Psychosocial Functioning 51 Functioning in ALL 3 major areas of life (occupational + social + recreational) 0 Good 3 Fair ( 1 problem area ) 6 Poor ( 2-3 problem areas ) Item 51: [Version Sept 27. prevents work ) Communication With Emotions 45 Loss of the ability to express or understand emotions. lack of creativity or curiosity 0 No or little difficulty 3 Much difficulty 6 Severe difficulty ( disabling. odd mannerisms / posturing) 0 No or little difficulty 3 Much difficulty 6 Severe difficulty ( disabling. or hopeless 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling. prevents work ) Apathy 41 Little interest or pleasure (e. toileting. sad.g. prevents work ) Communication With Words 44 Loss of the ability to use or understand words. prevents work ) Items 34-35: Hyperactivity or Agitation Excessive movement (e. prevents work ) 0 No or little difficulty 1 Much difficulty 2 Severe difficulty ( disabling. prevents work ) Delusions or Hallucinations 38 Bizarre false beliefs or perceptual distortions (e.. imaginary voices. dressing. decreased spontaneous emotion 0 No or little difficulty 3 Much difficulty 6 Severe difficulty ( disabling. or not awake enough to drive a car etc. depressed.. or problemsolving.

could feel guilt hence heeded correction and made amends Was untrustworthy. or made them feel unappreciated Copyright © 2004-2008 Phillip W. or steal [Version Sept 27. ignored correction. long-term goals which gave meaning and purpose to life lacked 2 … Emotional Instability Mood was unstable and unpredictable. cheat.Internet Mental Health SURNAME: SOCIAL QUALITY OF LIFE SCALE GIVEN NAME: DATE: MM www. love and play Spent excessive time working (when financially not required to work that hard) Was able to compromise. or took undue risks) 0 … Respect 2 … Disrespect 76 0 … Responsibility 2 … Irresponsibility 77 0 … Honesty Was honest 78 Treated others with respect and made them feel appreciated Treated others with disrespect. or sought revenge 55 0 … Friendship 2 … Social Withdrawal Preferred to be alone and didn’t enjoy the company of others 0 … Empathy Was sensitive to (and understood) other people’s feelings 0 … Love 2 … Lack of Emotion Seldom showed compassion. went from crisis to crisis 0 … Humility 2 … Arrogance 70 0 … Cooperation 2 … Exploitation of Others 71 0 … Generosity 2 … Entitlement 72 Was humble (not arrogant or grandiose} Cooperated with others for a common purpose (and did a fair share of the work) Sought self-benefit at the expense of others.com DD YY FOR THE PAST 7 DAYS RATE IF YOU SHOWED MORE “0” OR “2” 0 … Trust Trusted people and wasn’t overly suspicious 52 0 … Forgiveness Forgave other peoples’ mistakes. M. long-term meaning and purpose to life goals. was disposed to lie. affection (was distant or aloof) kindness 57 Preferred to be with friends and enjoyed their company Showed compassion. Was trustworthy. did not forgive someone’s mistake. or felt very envious or jealous 56 2 … Mistrust Was overly suspicious and didn’t trust people 2 … Bearing Grudges Bore a grudge. often had emotional outbursts of anger or crying 2 … Social Instability Social life was unstable and stormy. 2009] (Permission Granted For Non-commercial Reprinting + Use In Research) . saw merit in an opponent’s viewpoint 0 … Emotional Stability Mood was stable and predictable 67 0 … Purpose In Life 2 … Life Lacking Purpose Lacked realistic. Long. kindness or affection 2 … Lack of Empathy Was callous or insensitive to other people’s feelings (did not try to understand how they felt) 58 or 0 … Courage 2 … Lack of Self-Confidence 0 … Hope Was optimistic and expected to succeed 59 0 … Companionship 2 … Loneliness Felt lonely with nobody to talk to 60 Was self-confident and acted on own convictions (even if they were unpopular) Lacked self-confidence or did not act decisively Usually had a companion and didn’t feel lonely 2 … Pessimism Was pessimistic or defeatist (expected to fail) 0 … Independence Did not fear being alone (or being temporarily separated from loved ones) 61 0 … Leadership Acted as a leader to organize a group to get things done 62 0 … Peacemaking Skillfully prevented (or handled) conflict within a group or family 63 2 … Fear of Abandonment Feared being alone or separated from loved ones 2 … Submissiveness Acted as a follower (submissively following the leadership of others) 64 2 … Difficulty Handling Conflict Found it hard to handle conflict with others (or actively avoided conflict with others) 0 … Moderation 2 … Perfectionism Demanded perfection from self and others 0 … Balanced Life 2 … Excessive Working … N/A 65 0 … Compromise 2 … Stubbornness Was inflexible and unable to compromise 66 Set realistic goals.mentalhealth. 68 0 … Social Stability Social life was stable and peaceful 69 Had realistic.D. lacked remorse of guilt. conned or manipulated others Unselfishly helped others by giving time or money (without expecting personal gain) Unreasonably expected especially favorable treatment or automatic obedience Was arrogant with a highly inflated sense of selfworth and superiority 0 … Genuineness 2 … Attention-Seeking Needed excessive attention (tried to be the center of attention and was overly dramatic) 73 0 … Chastity 2 … Promiscuity … N/A 74 0 … Caution Showed caution and thought carefully before acting or speaking 75 Was genuine (not overly dramatic or attention-seeking) Did not have casual sex (with someone who was not a permanent sex partner) Had casual sex OR had intense desire for illicit sex 2 … Impulsivity Was too impulsive (did not think carefully before acting or speaking. and didn’t bear a grudge or seek revenge 53 0 … Gratitude 2 … Feeling Victimized 54 Was thankful for the good things in life and expressed thanks to others Felt exploited or abused by someone. accepted “good enough” rather than demanding perfection Maintained a proper balance between work. didn’t make amends 2 … Dishonesty Was dishonest.