Optional Health Assessment Modules Form Page 7
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27OPTIONAL MODULE 4:
UR Number:
PSYCHECK
Surname:
Given name:
Date of birth:
(Please fill in if no label available)
SELF REPORTING QUESTIONNAIRE
(CLIENT OR CLINICIAN TO COMPLETE)
The PsyCheck Screening Tool is designed to be used in conjunction with the PsyCheck Clinical Treatment Guidelines.
1. 1. Please tick the ‘Yes’ box if you have had this symptom in the last 30 days.
2. 2. Look back over the questions you have ticked. For every one you answered ‘Yes’, please
put a tick in the circle if you had that problem at a time when you were NOT using alcohol or other drugs.
3.
1
Do you often have headaches?
No
Yes
4.
2
Is your appetite poor?
No
Yes
5.
3
Do you sleep badly?
No
Yes
6.
4
Are you easily frightened?
No
Yes
7.
5
Do your hands shake?
No
Yes
8.
6
Do you feel nervous?
No
Yes
9.
7
Is your digestion poor?
No
Yes
10. 8
Do you have trouble thinking clearly?
No
Yes
11. 9
Do you feel unhappy?
No
Yes
12. 10
Do you cry more than usual?
No
Yes
13. 11
Do you find it difficult to enjoy your daily activities?
No
Yes
14. 12
Do you find it difficult to make decisions?
No
Yes
15. 13
Is your daily work suffering?
No
Yes
16. 14
Are you unable to play a useful part in life?
No
Yes
17. 15
Have you lost interest in things?
No
Yes
18. 16
Do you feel that you are a worthless person?
No
Yes
19. 17
Has the thought of ending your life been on your mind?
No
Yes
20. 18
Do you feel tired all the time?
No
Yes
21. 19
Do you have uncomfortable feelings in the stomach?
No
Yes
22. 20
Are you easily tired?
No
Yes
Total score (add circles only):
FOR STAFF ONLY
Clinician name:
Position:
Signature:
Date:
6
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