GPH K-10 Assessment Form

K-10 Assessment Form

If you do not want to complete this form or need help, you can leave this page and talk to your GPH worker.

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K-10

The following ten questions ask about how you have been feeling in the last four weeks. For each question, mark the circle under the option that best describes the amount of time you felt that way.

None of the time

A little of the time

Some of the time

Most of the time

All of the time

In the last four weeks, about how often did you feel tired out for no good reason?

In the last four weeks, about how often did you feel nervous?

In the last four weeks, about how often did you feel so nervous that nothing could calm you down?

In the last four weeks, about how often did you feel hopeless?

In the last four weeks, about how often did you feel restless or fidgety?

In the last four weeks, about how often did you feel so restless you could not sit still?

In the last four weeks, about how often did you feel depressed?

In the last four weeks, about how often did you feel that everything was an effort?

In the last four weeks, about how often did you feel so sad that nothing could cheer you up?

In the last four weeks, about how often did you feel worthless?

K-10 Plus

The next few questions are about how these feelings may have affected you in the last four weeks. You do not need to answer these questions if you answered ‘None of the time’ to all of the ten questions above.

In the last four weeks, how many days were you totally unable to work, study or manage your day to day activities because of these feelings?

Please enter number of days.

Aside from the days you were unable to work or study, in the last 4 weeks, how many days were you able to work or study or manage your day to day activities, but had to cut down on what you did because of these feelings?

Please enter number of days.

In the last 4 weeks, how many times have you seen a doctor or any other health professional about these feelings?

Please enter number of days.

In the last 4 weeks, how often have physical health problems been the main cause of these feelings?

None of the time

A little of the time

Some of the time

Most of the time