info@rakipipsychologicalservices.com
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Address: 170 State Street, Brooklyn, NY 11201
Phone: 718-313-6870
Email: info@rakipipsychologicalservices.com
Sefedin Rakipi, Psy. D. Clinical Psychologist
Name:
Date:
Instructions: This questionnaire consists of 21 groups of statements. Please read each group carefully. Then pick out the one statement in each group that best describes the way you have been feeling during the past two weeks, including today.
1) Sadness
I do not feel sad.I feel sad much of the time.I am sad all the time.I am so sad or unhappy that I can't stand it.
2) Pessimism
I am not discouraged about my future.I feel more discouraged about my future than I used to.I do not expect things to work out for me.I feel my future is hopeless and will only get worse.
3) Past Failure
I do not feel like a failure.I have failed more than I should have.As I look back, I see a lot of failures.I feel I am a total failure as a person.
4) Loss of Pleasure
I get as much pleasure as I ever did from the things I enjoy.I don't enjoy things as much as I used to.I get very little pleasure from the things I used to enjoy.I can't get any pleasure from the things I used to enjoy.
5) Guilty Feelings
I don't feel particularly guilty.I feel guilty over many things I have done or should have done.I feel quite guilty most of the time.I feel guilty all of the time.
6) Punishment Feelings
I don't feel I am being punished.I feel I may be punished.I expect to be punished.I feel I am being punished.
7) Self-Dislike
I feel the same about myself as ever.I have lost confidence in myself.I am disappointed in myself.I dislike myself.
8) Self-Criticalness
I don't criticize or blame myself more than usual.I am more critical of myself than I used to be.I criticize myself for all of my faults.I blame myself for everything bad that happens.
9) Suicidal Thoughts or Wishes
I don't have any thoughts of killing myself.I have thoughts of killing myself, but I would not carry them out.I would like to kill myself.I would kill myself if I had the chance.
10) Crying
I don't cry any more than I used to.I cry more than I used to.I cry over every little thing.I feel like crying, but I can't.
11) Agitation
I am no more restless or wound up than usual.I feel more restless or wound up than usual.I am so restless or agitated, it's hard to stay still.I am so restless or agitated that I have to keep moving or doing something.
12) Loss of Interest
I have not lost interest in other people or activities.I am less interested in other people or things than before.I have lost most of my interest in other people or things.It's hard to get interested in anything.
13) Indecisiveness
I make decisions about as well as ever.I find it more difficult to make decisions than usual.I have much greater difficulty making decisions than I used to.I have trouble making any decisions.
14) Worthlessness
I do not feel I am worthless.I don't consider myself as worthwhile and useful as I used to.I feel more worthless as compared to other people.I feel utterly worthless.
15) Loss of Energy
I have as much energy as ever.I have less energy than I used to have.I don't have enough energy to do very much.I don't have enough energy to do anything.
16) Changes in Sleeping Pattern
I have not experienced any change in my sleeping.I sleep somewhat more than usual.I sleep somewhat less than usual.I sleep a lot more than usual.I sleep a lot less than usual.I sleep most of the day.I wake up 1-2 hours early and can't get back to sleep.
17) Irritability
I am no more irritable than usual.I am more irritable than usual.I am much more irritable than usual.I am irritable all the time.
18) Changes in Appetite
I have not experienced any change in my appetite.My appetite is somewhat less than usual.My appetite is somewhat greater than usual.My appetite is much less than before.My appetite is much greater than usual.I have no appetite at all.I crave food all the time.
19) Concentration Difficulty
I can concentrate as well as ever.I can't concentrate as well as usual.It's hard to keep my mind on anything for very long.I find I can't concentrate on anything.
20) Tiredness or Fatigue
I am no more tired or fatigued than usual.I get more tired or fatigued more easily than usual.I am too tired or fatigued to do a lot of the things I used to do.I am too tired or fatigued to do most of the things I used to do.
21) Loss of Interest in Sex
I have not noticed any recent change in my interest in sex.I am less interested in sex than I used to be.I am much less interested in sex now.I have lost interest in sex completely.
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Today's Date:
Patient Name:
Date of Birth:
Your address:
Email:
Date of Accident:
Referral Source:
WC Insurance Name:
WC Number:
Adjuster’s name/phone:
Attorney Name:
Attorney Phone Number:
Accident (briefly describe how you got hurt):
Describe the Accident:
What body parts were injured:
Did you get any surgeries:
What treatment you’re received:
Name Treatment
Medication Frequency
Pain management Dr.
Psychology
Neurologist
Cognitive therapy
Psychiatrist
Physical therapy
Date of Visit:
Over the past 2 weeks, how often haveyou been bothered by any of the following problems?
Not at all 0
Several days 1
More than half the days 2
Nearly every day 3
1. Little interest or pleasure in doing things
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2. Feeling down, depressed, or hopeless
3. Trouble falling asleep, 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 a lot more than usual
9. Thoughts that you would be better off dead or of hurting yourself in some way
Column Totals
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Add Totals Together
Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by circling the number in the corresponding space in the column next to each symptom.
Mildly, but it didn't bother me much 1
Moderately – it wasn't pleasant at times 2
Severely – it bothered me a lot 3
Numbers or tingling
Feeling hot
Wobbliness in legs
Unable to relax
Fear of worst happening
Dizzy or lightheaded
Heart pounding / racing
Unsteady
Terrified or afraid
Nervous
Feeling of choking
Hands trembling
Shaky / unsteady
Fear of losing control
Difficulty in breathing
Fear of dying
Scared
Indigestion
Faint / lightheaded
Face flushed
Hot / cold sweats
Pain Catastrophizing Scale (Copyright 1995, 2001, 2004, 2006, 2009 Michael JL Sullivan, PhD) Everyone experiences painful situations at some point in their lives. Such experiences may include headaches, tooth pain, joint or muscle pain. People are often exposed to situations that may cause pain such as illness, injury, dental procedures or surgery
We are interested in the types of thoughts and feeling that you have when you are in pain. Listed below are thirteen statements describing different thoughts and feelings that may be associated with pain. Using the scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain.
To a slight degree 1
To a moderate degree 2
To a great degree 3
All the time 4
1. I worry all the time about whether the pain will end
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2. I feel I can't go on
3. It's terrible and I think it's never going to get any better
4. It's awful and I feel that it overwhelms me
5. I feel I can't stand it anymore
6. I become afraid that the pain will get worse
7. I keep thinking of other painful events
8. I anxiously want the pain to go away
9. I can't seem to keep it out of my mind
10. I keep thinking about how much it hurts
11. I keep thinking about how badly I want the pain to stop
12. There's nothing I can do to reduce the intensity of the pain
13. I wonder whether something serious may happen
