The purpose of this evaluation is to make you aware of your current condition.
We would like you to rate your emotional state and well being during the last two weeks.
You will be asked to answer 9 questions to state your feelings from total lack of discomfort (0) to a maximum feeling (6) of unease. Use the sliding control to state your answer as viewed in the example below. Remember you are rating your last two weeks.
0 Heres a statement where you experiencing minimal discomfort.
2 Heres a statement where you occasionally have a feeling of discomfort.
4 Heres a statement where you often have a feeling of discomfort.
6 Heres a statement where you have a maximal feeling of discomfort.
I answered: 0
1 Ability to concentrate
We would like you to assess your ability to keep your thoughts together and concentrate on various activities. Think about how you function in various activities that demand different levels of concentration, e.g. reading a complicated text, reading a newspaper article and watching TV.
0 I do not have any difficulty concentrating, and can read, watch TV and converse normally.
2 I occas ionally have difficulty keeping my thoughts together on things that would normally hold my attention.
4 I have often difficulty concentrating.
6 I cannot concentrate on anything at all.
I answered: 0
2 Memory
We ask here that you describe your ability to remember things. Think about whether or not you have had difficulty recalling names, dates, or tasks that you intend to do during a regular day.
0 I remember names, dates, and what I am supposed to do.
2 Sometimes I forget things that are not so important, but if I pull myself together I can usually
remember.
4 I often forget appointments or names of people whom I know very well.
6 Every day, I forget important things or what I have promised to do.
I answered: 0
3 Physical stamina
This i s a question concerning your physical stamina. Do you feel, for example, more exhausted than usual after the activities of an ordinary day or some form of physical exertion?
0 I feel the way I usually do and perform my daily physical activities or exercise as usual.
2 I feel that physical effort is more exhausting than normal, but still move the way I usually do in this respect.
4 I do not have the energy to exert myself physically. It is OK as long as I move at a normal phase, but I c annot increase my pace without becoming shaky and short of breath.
6 I feel very weak and cannot even move short distances.
I answered: 0
4 Mental stamina
We would like you to reflect here on your mental stamina and to what extent you are more mentally
exhausted than usual in various everyday situations.
0 I have just as much energy as usual. I do not have any particular difficult performing my daily activities.
2 I can manage my everyday activities, but they take more energy and I am exhausted more quickly than usual. I need to take breaks more often than usual.
4 I become inordinately tired when I attempt my daily activities and find social situations exhausting.
6 I do not have the energy to do anything.
I answered: 0
5 Recovery
We ask you to describe here how well and how quickly you recover mentally and physically when you have been exhausted.
0 I do not have to rest during the day.
2 I become tired during the day, but all I have to do is to take a little break in order to recover.
4 I become tired during the day and need to take long breaks in order to feel fit.
6 No matter how much I rest, it feels as if I am unable to recharge my batteries.
I answered: 0
6 Sleep
We ask you to describe your sleep. Think about how long you have slept and the quality of your sleep during the past two weeks. Your assessment should reflect your actual sleep, regardless of whether or not you have taken sleeping pills.
0 I sleep well and long enough. I usually feel thoroughly rested when I wake up after a night’s sleep.
2 Sometimes, I sleep more restlessly than usual, or wake up during the night and have difficulty going back to sleep. Sometimes, I do not feel thoroughly rested when I wake up after a night’s sleep.
4 I often sleep more restlessly than usual, or wake up during the night and have difficulty going back to sleep. I often have a feeling of not being thoroughly rested after a night’s sleep.
6 I sleep superficially or restlessly every night. I never feel thoroughly rested after a night’s sleep.
I answered: 0
7 Hypersensitivity to sensory impressions
This is a question about the extent to which one or several of your senses have become more sensitive to
impressions, such as sound, light, smell or touch.
0 I do not think that my senses are more sensitive than usual.
2 Sound or light or other sensory impressions are sometimes unpleasant.
4 I often experience that sound, light or other sensory impressions are disturbing or unpleasant.
6 Sound, light or other sensory impressions bother me so much that I withdraw in order to give my senses a chance to rest.
I answered: 0
8 Experience of demands
Here we ask you to give expression to the way you react to demands in your daily life. These demands can come from your surroundings or be your own demands on yourself.
0 I do what I am supposed to do or want to do without experiencing it as especially demanding or
difficult.
2 Sometimes I experience daily situations that I used to handle without any particular problem as demanding, leading to unease, or causing me to become more easily stressed.
4 I often feel that situations that I previously handled without problem are now demanding and cause a strong feeling of uneasiness or stress.
6 l experience nearly everything as demanding and cannot handle it at all.
I answered: 0
9 Irritation and anger
This question regards how easily irritated or angry you become, regardless of whether or not you show it. Think especially about how quick tempered you have been in relationship to the source of your irritation, and how often and intensively you have become angry or irritated. If you have not had any such feelings at all, then you should mark “0.”
0 I do not feel that I am especially easily irritated.
2 I am more impatient and easily irritated than usual, but the feeling quickly passes.
4 I become more impatient and easily irritated than usual. Sometimes I lose control in a way that is unusual for me.
6 I am often furious and have to make an enormous effort in order to restrain myself.
I answered: 0
Optional information
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