Wellness – Bodycomp

Burnout Rating Scale

Burnout Rating Scale

Think over the past 3 months and score the following questions according to how often you have experienced these symptoms. 0=Never 1=Very rarely 2=Rarely 3=Sometimes 4=Often 5=Very often

1. Do you feel fatigued in a way that rest or sleep does not releive?
- Never
- Very rarely
- Rarely
- Sometimes
- Often
- Very often
2. Do you feel more cynical, pessimistic or dillusional about things you used to feel positive about?
- Never
- Very rarely
- Rarely
- Sometimes
- Often
- Very often
3. Do you feel sadness or emptiness inside?
- Never
- Very rarely
- Rarely
- Sometimes
- Often
- Very often
4. Do you have physical symptoms of stress, eg. insomnia, stomach pain, headaches, migranes?
- Never
- Very rarely
- Rarely
- Sometimes
- Often
- Very often
5. Is your memory unreliable?
- Never
- Very rarely
- Rarely
- Sometimes
- Often
- Very often
6. Are you irritable or emotional with a short fuse?
- Never
- Very rarely
- Rarely
- Sometimes
- Often
- Very often
7. Have you been more suseptible to illness lately, eg. colds, flu, food, allegies, hay fever?
- Never
- Very rarely
- Rarely
- Sometimes
- Often
- Very often
8. Do you feel like isolating yourself from colleagues, friends or family?
- Never
- Very rarely
- Rarely
- Sometimes
- Often
- Very often
9. Is it hard to enjoy yourself, have fun, relax and experience joy in your life?
- Never
- Very rarely
- Rarely
- Sometimes
- Often
- Very often
10. Do you feel that you are accomplishing less in your work?
- Never
- Very rarely
- Rarely
- Sometimes
- Often
- Very often
My Score:
Date
Date Format: MM slash DD slash YYYY
Other
Other indicators of being over stressed or approaching burnout for me are:
Score of 0 -15: You are doing well.

Score of 16 - 25: Some attention needed, you may be a candidate.
Warning!
Score above 25 you may be a candidate.
More information
Please "take a knee" if you feel you might need to!
Name
This field is for validation purposes and should be left unchanged.

Stress

Perceived Stress Scale

The questions in this scale ask you about your feelings and thoughts during THE LAST MONTH. In each case, you will be asked to indicate your response by indicating HOW OFTEN you felt or thought a certain way. Although some of the questions are similar, there are differences between them and you should treat each one as a separate question. The best approach is to answer fairly quickly. That is, don’t try to count up the number of times you felt a particular way, but rather indicate the alternative that seems like a reasonable estimate. 0 = Never 1 = Almost Never 2 = Sometimes 3 = Fairly Often 4 = Very Often 0=Never 1=Very rarely 2=Rarely 3=Sometimes 4=Often 5=Very often

1. In the last month, how often have you been upset because of something that happened unexpectedly?
- Never
- Almost Never
- Sometimes
- Fairly Often
- Very Often
2. In the last month, how often have you felt that you were unable to control the important things in your life?
- Never
- Almost Never
- Sometimes
- Fairly Often
- Very Often
3. In the last month, how often have you felt nervous and “stressed”?
- Never
- Almost Never
- Sometimes
- Fairly Often
- Very Often
4. In the last month, how often have you dealt successfully with day to day problems and annoyances?
- Never
- Almost Never
- Sometimes
- Fairly Often
- Very Often
5. In the last month, how often have you felt that you were effectively coping with important changes that were occurring in your life?
- Never
- Almost Never
- Sometimes
- Fairly Often
- Very Often
6. In the last month, how often have you felt confident about your ability to handle your personal problems?
- Never
- Almost Never
- Sometimes
- Fairly Often
- Very Often
7. In the last month, how often have you felt that things were going your way?
- Never
- Almost Never
- Sometimes
- Fairly Often
- Very Often
8. In the last month, how often have you found that you could not cope with all the things that you had to do?
- Never
- Almost Never
- Sometimes
- Fairly Often
- Very Often
9. In the last month, how often have you been able to control irritations in your life?
- Never
- Almost Never
- Sometimes
- Fairly Often
- Very Often
10. In the last month, how often have you felt that you were on top of things?
- Never
- Almost Never
- Sometimes
- Fairly Often
- Very Often
11. In the last month, how often have you been angered because of things that happened that were outside of your control?
- Never
- Almost Never
- Sometimes
- Fairly Often
- Very Often
12. In the last month, how often have you found yourself thinking about things that you have to accomplish?
- Never
- Almost Never
- Sometimes
- Fairly Often
- Very Often
13. In the last month, how often have you been able to control the way you spend your time?
- Never
- Almost Never
- Sometimes
- Fairly Often
- Very Often
14. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
- Never
- Almost Never
- Sometimes
- Fairly Often
- Very Often
Date
Date Format: MM slash DD slash YYYY
My Score:
Other
Other indicators of being over stressed or approaching burnout for me are:
Score of 0 -15: You are doing well.

Score of 16 - 25: Some attention needed, you may be a candidate.
Warning!
Score above 25 you may be a candidate.
More information
Please "take a knee" if you feel you might need to!
From: Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385-396. PERCEIVED STRESS SCALE by Sheldon Cohen http://www.mindgarden.com/documents
Comments
This field is for validation purposes and should be left unchanged.

Anxiety

Generalized Anxiety Disorder 7-item (GAD-7) scale

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

1. Over the last 2 weeks, how often have you been feeling nervous, anxious, or on edge?
- Not at all
- Several days
- Over half the days
- Nearly every day
2. Over the last 2 weeks, how often have you not being able to stop or control worrying?
- Not at all
- Several days
- Over half the days
- Nearly every day
3. Over the last 2 weeks, how often have you been worrying too much about different things?
- Not at all
- Several days
- Over half the days
- Nearly every day
4. Over the last 2 weeks, how often have you had trouble relaxing?
- Not at all
- Several days
- Over half the days
- Nearly every day
5. Over the last 2 weeks, how often have you been so restless that it's hard to sit still?
- Not at all
- Several days
- Over half the days
- Nearly every day
6. Over the last 2 weeks, how often have you been easily annoyed or irritable?
- Not at all
- Several days
- Over half the days
- Nearly every day
7. Over the last 2 weeks, how often have you been feeling afraid as if something awful might happen
- Not at all
- Several days
- Over half the days
- Nearly every day
Date
Date Format: MM slash DD slash YYYY
My Score:
Other
Other indicators of being over stressed or approaching burnout for me are:
Score of 0 -5: You are doing well.

Score of 6 - 10: Some attention needed. You may be a candidate for moderate anxiety.

Score of 15 or more: Further evaluation is recommended. You may be a candidate for severe anxiety.
Warning!
A score above 10 you may be a candidate.
More information
Please "take a knee" if you feel you might need to!
Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097. Scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate and severe anxiety, respectively. When used as a screening tool, further evaluation is recommended when the score is 10 or greater. Using the threshold score of 10, the GAD-7 has a sensitivity of 89% and a specificity of 82% for GAD. It is moderately good at screening three other common anxiety disorders - panic disorder (sensitivity 74%, specificity 81%), social anxiety disorder (sensitivity 72%, specificity 80%) and post-traumatic stress disorder (sensitivity 66%, specificity 81%).[3]
Email
This field is for validation purposes and should be left unchanged.

Depression

Depression (Personal Health Questionnaire PHQ-9)

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

1. Over the last 2 weeks have you been bothered by little interest or pleasure in doing things?
- Not at all
- Several days
- Over half the days
- Nearly every day
2. Over the last 2 weeks have you been bothered by feeling down, depressed, or hopeless?
- Not at all
- Several days
- Over half the days
- Nearly every day
3. Over the last 2 weeks have you been bothered by trouble falling asleep, or staying asleep, or sleeping too much?
- Not at all
- Several days
- Over half the days
- Nearly every day
4. Over the last 2 weeks have you been bothered by feeling tired or having little energy?
- Not at all
- Several days
- Over half the days
- Nearly every day
5. Over the last 2 weeks have you been bothered by poor appetite or overeating?
- Not at all
- Several days
- Over half the days
- Nearly every day
6. Over the last 2 weeks have you been bothered by feeling bad about yourself - or that you are a failure, or have let yourself or your family down?
- Not at all
- Several days
- Over half the days
- Nearly every day
7. Over the last 2 weeks have you been bothered by trouble concentrating on things, such as reading the newspaper or watching television?
- Not at all
- Several days
- Over half the days
- Nearly every day
8. Over the last 2 weeks have you been bothered by moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around more than usual?
- Not at all
- Several days
- Over half the days
- Nearly every day
9. Over the last 2 weeks have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?
- Not at all
- Several days
- Over half the days
- Nearly every day
Date
Date Format: MM slash DD slash YYYY
My Score:
Other
Other indicators of being over stressed or approaching burnout for me are:
Score of 0-4: Patient not likely depressed, re-screen if affect changes. Communicate results to the team and to any referral sites.

Score of 5-9: Watchful waiting - patient to be closely monitored and re-screened if needed. Communicate results to the team and any referral sites.

Score of 9 or more: Patient has screened positive and requires further assessment by a certified professional for diagnosis and treatment. Notify attending, consider consulting psychiatry or psychology. Communicate results to the team and any referral sites.
Warning!
A score above 10 you may be a candidate.
More information
Please "take a knee" if you feel you might need to!
Source: https://www.albertahealthservices.ca/frm-19825.pdf PHQ-9 is adapted from PRIME MD TODAY, Copyright© 1999 Pfizer Inc. All rights Reserved. Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. http://phqscreeners.com/pdfs/02_PHQ-9/English.pdf
Phone
This field is for validation purposes and should be left unchanged.

Substance Abuse

Substance Use Self Assessment Quiz

Please consider the following which sometimes occur after a traumatic event. This questionnaire is concerned with your personal reactions to the traumatic event which happened to you. Please indicate (Yes/No) whether or not you have experienced any of the following at least twice in the past week.

1. Do you drink or use to overcome shyness or to feel more confident?
- No
- Yes
2. Are you having money troubles because of drinking or using?
- No
- Yes
3. Do you ever stay home from work because of drinking or using?
- No
- Yes
4. Is drinking or using causing trouble in your family?
- No
- Yes
5. Is drinking or using giving you a bad reputation?
- No
- Yes
6. Have you lost a job or a business because of drinking or using?
- No
- Yes
7. Do you drink or use to escape your problems?
- No
- Yes
8. Do you drink or use when you are alone?
- No
- Yes
9. Do you have blackouts? (Loss of memory for events that happened or of actions you performed while drinking or using?)
- No
- Yes
10. Do you feel remorse after drinking or using?
- No
- Yes
11. Do you need a drink at a definite time every day?
- No
- Yes
12. Do you drink in the morning?
- No
- Yes
13. Have you ever been in a hospital because of drinking or using?
- No
- Yes
14. Has a doctor ever treated you for your drinking or using?
- No
- Yes
15. Do you drink or use too much at the wrong time?
- No
- Yes
16. Do you make promises to yourself or others about your drinking or using?
- No
- Yes
17. Do you have to keep on drinking or using once you have started?
- No
- Yes
18. Is drinking or using making it hard for you to sleep?
- No
- Yes
19. Have you had an accident because of drinking or using?
- No
- Yes
20. Do you drink or use to relieve the painfulness of living?
- No
- Yes
21. Do you have trouble disposing of cans or bottles?
- No
- Yes
22. Are you less particular about people you are with and the places you go when you are drinking or using?
- No
- Yes
23. Have you been arrested more than once for drunk driving or driving under the influence of drugs?
- No
- Yes
24. Has drinking or using affected your health?
- No
- Yes
My Score:
Date
Date Format: MM slash DD slash YYYY
Other
Other indicators of being over stressed or approaching burnout for me are:
If you have answered "Yes" to any of these questions, you may have an alcohol or drug problem.

One “YES” answer: BE AWARE. You may have or you may develop a problem with alcohol or other drugs.

Two or more “YES” answers: Indicates you have problems with alcohol and/or drugs and should seek help immediately.

If you believe that you have or that you may have a problem with alcohol or other drugs, we can help. Learn more about our drug and alcohol rehabilitation programs.
Warning!
If you answered yes to 2 or more questions you are encouraged to consider whether you think that some counselling support may be beneficial in helping you.
More information
Please "take a knee" if you feel you might need to!
Source: https://www.cottonwooddetucson.com/drug-alcohol-self-assessment
Comments
This field is for validation purposes and should be left unchanged.

Trauma Scene Questionnaire

Trauma Screening Questionnaire (TSQ)

1. Upsetting thoughts or memories about the event that have come into your mind against your will?
- No
- Yes
2. Upsetting dreams about event?
- No
- Yes
3. Acting or feeling as though the event were happening again?
- No
- Yes
4. Feeling upset be reminders of the event?
- No
- Yes
5. Bodily reactions (such as fast heartbeat, stomach churning, sweatiness, dizziness) when reminded of the event?
- No
- Yes
6. Difficulty falling or staying asleep?
- No
- Yes
7. Irratability or outbursts of anger?
- No
- Yes
8. Difficulty concentrating?
- No
- Yes
9. Heightened awareness of potential dangers to yourself and others?
- No
- Yes
10. Being jumpy or being startled at something unexpected?
- No
- Yes
My Score:
Date
Date Format: MM slash DD slash YYYY
Other
Other indicators of being over stressed or approaching burnout for me are:
Score of 0 -5: You are doing well.

Score of 6 - 10: Some attention needed, you may be a candidate.
Warning!
If you answered yes to 6 or more questions you are encouraged to consider whether you think that some counselling support may be beneficial in helping you to lower your on-going reactions to the traumatic event.
More information
Please "take a knee" if you feel you might need to!
Email
This field is for validation purposes and should be left unchanged.

More ratings to be added soon!

Burnout Rating Scale

Perceived Stress Scale

Generalized Anxiety Disorder 7-item (GAD-7) scale

Depression (Personal Health Questionnaire PHQ-9)

Substance Use Self Assessment Quiz

Trauma Screening Questionnaire (TSQ)

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