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Client Questionnaire

These questions help us understand how you're doing now, and track changes over time. Please answer each question based on your experience during the timeframe specified. There are no right or wrong answers. Choose the response that best reflects your experience. The takes approximately 3–5 minutes to complete. Thank you!

First name

Last name

Phone number

Email

Please think about how you've felt in the last seven days.

Even if I am somewhere else with my thoughts, I can focus on what’s going on in important moments. *

1 very seldom

2 seldom

3 sometimes

4 often

5 very often

I can accept unpleasant experiences and thoughts if they help me to do what is important to me. *

1 very seldom

2 seldom

3 sometimes

4 often

5 very often

I can look at hindering thoughts from a distance without letting them control me. *

1 very seldom

2 seldom

3 sometimes

4 often

5 very often

Even if my thoughts and experiences are confusing me, I can notice something like a steady core inside of me. *

1 very seldom

2 seldom

3 sometimes

4 often

5 very often

I can determine what’s important for me in life and decide how I want to live based on that. *

1 very seldom

2 seldom

3 sometimes

4 often

5 very often

I engage thoroughly in things that are important, useful, or meaningful to me. *

1 very seldom

2 seldom

3 sometimes

4 often

5 very often

Over the last 2 weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious, or on edge? *

0 not at all

1 several days

2 more than half the days

3 nearly every day

Not being able to stop or control worrying *

0 not at all

1 several days

2 more than half the days

3 nearly every day

Little interest or pleasure in doing things *

0 not at all

1 several days

2 more than half the days

3 nearly every day

Feeling down, depressed, or hopeless *

0 not at all

1 several days

2 more than half the days

3 nearly every day

Please indicate how much the following statements have been true for you over the past month.

Able to adapt to change *

0 not true at all

1 rarely true

2 sometimes true

3 often true

4 true nearly all of the time

Tend to bounce back after illness or hardship *

0 not true at all

1 rarely true

2 sometimes true

3 often true

4 true nearly all of the time

Thinking about the past month, to what extent has poor sleep troubled you in general? *

4 not at all

3 a little

2 somewhat

1 much

0 very much

Thinking about a typical night in the last month, how many nights a week do you have a problem with your sleep? *

4 = 0-1 nights

3 = 2 nights

2 = 3 nights

1 = 4 nights

0 = 5-7 nights

Thinking about the past week, please select the number that best describes your pain and its impact.

What number best describes your pain on average in the past week? *

0 = no pain

1

2

3

4

5

6

7

8

9

10 = pain as bad as you can imagine

What number best describes how, during the past week, pain has interfered with your enjoyment of life? *

0 = does not interfere

1

2

3

4

5

6

7

8

9

10 = completely interferes

What number best describes how, during the past week, pain has interfered with your general activity? *

0 = does not interfere

1

2

3

4

5

6

7

8

9

10 = completely interferes

The following questions are about your overall quality of life. Please select the number that best reflects your experience.

All things considered, how satisfied are you with your life nowadays? *

0 not at all satisfied

1

2

3

4

5

6

7

8

9

10 completely satisfied

To what extent do you feel that the things you do in your life are meaningful? *

0 not at all meaningful

1

2

3

4

5

6

7

8

9

10 completely meaningful

Taking all things together, how happy would you say you have been during the past 7 days? *

0 not at all happy

1

2

3

4

5

6

7

8

9

10 completely happy

Thank you

Healing for People - An Energy Medicine Clinic in Orange County, Florida

Healing for People - An Energy Medicine Clinic

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