Optional Health Assessment Modules Form Page 6
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27UR Number:
Surname:
Given name:
Date of birth:
(Please fill in if no label available)
11
In the past month, were you afraid or embarrassed when others were watching you, or when you were the focus of attention?
No
Yes
Were you afraid of being humiliated?
Examples include: speaking in public; eating in public or with others; writing while someone watches; being in social
situations.
12
In the past month, have you been bothered by thoughts, impulses, or images that you couldn’t get rid of that were unwanted,
No
Yes
distasteful, inappropriate, intrusive or distressing?
Examples include: Were you afraid that you would act on some impulse that would be really shocking? Did you worry a lot
about being dirty, contaminated or having germs? Did you worry a lot about contaminating others, or that you would harm
someone even though you didn’t want to? Did you have any fears or superstitions that you would be responsible for things
going wrong? Were you obsessed with sexual thoughts, images or impulses? Did you hoard or collect lots of things? Did you
have religious practice obsessions?
13
In the past month, did you do something repeatedly without being able to resist doing it?
No
Yes
Examples include: washing or cleaning excessively; counting or checking things over and over; repeating, collecting, or
arranging; other superstitious rituals.
14
Have you ever experienced or witnessed or had to deal with an extremely traumatic event that included actual or threatened
No
Yes
death or serious injury to you or someone else?
Examples Include: serious accidents; sexual or physical assault; terrorist attack; being held hostage; kidnapping; fire;
discovering a body; sudden death of someone close to you; war; natural disaster.
15
Have you re-experienced the awful event in a distressing way in the past month?
No
Yes
Examples include: dreams; intense recollections; flashbacks; physical reactions.
16
Have you ever believed that people were spying on you, or that someone was plotting against you, or trying to hurt you?
No
Yes
17
Have you ever believed that someone was reading your mind or could hear your thoughts, or that you could actually read
No
Yes
someone’s mind or hear what another person was thinking?
18
Have you ever believed that someone or some force outside of yourself put thoughts in your mind that were not your own, or
No
Yes
made you act in a way that was not your usual self? Or, have you ever felt that you were possessed?
19
Have you ever believed that you were being sent special messages through the TV, radio, or newspaper? Did you believe that
No
Yes
someone you did not personally know was particularly interested in you?
20
Have your relatives or friends ever considered any of your beliefs strange or unusual?
No
Yes
21
Have you ever heard things other people couldn’t hear, such as voices?
No
Yes
22
Have you ever had visions when you were awake or have you ever seen things other people couldn’t see?
No
Yes
TOTAL YES RESPONSES
Likelihood of mental illness
Score of 0-5 = low
Score of 6-9 = moderate
Score of 10-22 = high
FOR STAFF ONLY
Clinician name:
Position:
Signature:
Date:
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