Minimum Data Set Questionnaire Phq-9 Template/form Gad-7 Page 2

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Phobia scales
Choose a number from the scale below to show how much you would avoid each of the situations or objects
listed below. Then write the number in the box opposite the situation.
0
1
2
3
4
5
6
7
8
Would not
Slightly
Definitely
Markedly
Always
avoid it
avoid it
avoid it
avoid it
avoid it
1
Social situations due to a fear of being embarrassed or making a fool of myself
Certain situations because of a fear of having a panic attack or other distressing symptoms (such
2
as loss of bladder control, vomiting or dizziness)
Certain situations because of a fear of particular objects or activities (such as animals, heights,
3
seeing blood, being in confined spaces, driving or flying).
Employment Status Questions
Please indicate which of the following options best describes your current status:
Employed full-time (30 hours or more per week)
Employed part-time
Unemployed
Full-time student
Retired
Full-time homemaker or carer
Are you currently receiving Statutory Sick Pay?
Yes
No
Are you currently receiving Job Seekers Allowance, Income support or Incapacity benefit?
Yes
No
W&SAS
People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your
problems look at each section and determine on the scale provided how much your problem impairs your ability
to carry out the activity.
1 WORK - if you are retired or choose not to have a job for reasons unrelated to your problem, please tick N/A
(not applicable)
0
1
2
3
4
5
6
7
8
N/A
Not at all
Slightly
Definitely
Markedly
Very severely,
I cannot work
2 HOME MANAGEMENT – Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc.
0
1
2
3
4
5
6
7
8
Not at all
Slightly
Definitely
Markedly
Very severely
3 SOCIAL LEISURE ACTIVITIES - With other people, e.g. parties, pubs, outings, entertaining etc.
0
1
2
3
4
5
6
7
8
Not at all
Slightly
Definitely
Markedly
Very severely
4 PRIVATE LEISURE ACTIVITIES – Done alone, e.g. reading, gardening, sewing, hobbies, walking etc.
0
1
2
3
4
5
6
7
8
Not at all
Slightly
Definitely
Markedly
Very severely
5 FAMILY AND RELATIONSHIPS – Form and maintain close relationships with others including the people that I
live with.
0
1
2
3
4
5
6
7
8
Not at all
Slightly
Definitely
Markedly
Very severely
W&SAS total score:
Minimum Data Set (MDS) questionnaire
2

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