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?NeverVery rarelyRarelySometimesOftenVery often2. Do you feel more cynical, pessimistic or dillusional about things you used to feel positive about?NeverVery rarelyRarelySometimesOftenVery often3. Do you feel sadness or emptiness inside?NeverVery rarelyRarelySometimesOftenVery often4. Do you have physical symptoms of stress, eg. insomnia, stomach pain, headaches, migranes?NeverVery rarelyRarelySometimesOftenVery often5. Is your memory unreliable?NeverVery rarelyRarelySometimesOftenVery often6. Are you irritable or emotional with a short fuse?NeverVery rarelyRarelySometimesOftenVery often7. Have you been more suseptible to illness lately, eg. colds, flu, food, allegies, hay fever?NeverVery rarelyRarelySometimesOftenVery often8. Do you feel like isolating yourself from colleagues, friends or family?NeverVery rarelyRarelySometimesOftenVery often9. Is it hard to enjoy yourself, have fun, relax and experience joy in your life?NeverVery rarelyRarelySometimesOftenVery often10. Do you feel that you are accomplishing less in your work?NeverVery rarelyRarelySometimesOftenVery oftenMy Score:Date Date Format: MM slash DD slash YYYY OtherOther 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 informationPlease "take a knee" if you feel you might need to!NameThis 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?NeverAlmost NeverSometimesFairly OftenVery Often2. In the last month, how often have you felt that you were unable to control the important things in your life?NeverAlmost NeverSometimesFairly OftenVery Often3. In the last month, how often have you felt nervous and “stressed”?NeverAlmost NeverSometimesFairly OftenVery Often4. In the last month, how often have you dealt successfully with day to day problems and annoyances?NeverAlmost NeverSometimesFairly OftenVery Often5. In the last month, how often have you felt that you were effectively coping with important changes that were occurring in your life?NeverAlmost NeverSometimesFairly OftenVery Often6. In the last month, how often have you felt confident about your ability to handle your personal problems?NeverAlmost NeverSometimesFairly OftenVery Often7. In the last month, how often have you felt that things were going your way?NeverAlmost NeverSometimesFairly OftenVery Often8. In the last month, how often have you found that you could not cope with all the things that you had to do?NeverAlmost NeverSometimesFairly OftenVery Often9. In the last month, how often have you been able to control irritations in your life?NeverAlmost NeverSometimesFairly OftenVery Often10. In the last month, how often have you felt that you were on top of things?NeverAlmost NeverSometimesFairly OftenVery Often11. In the last month, how often have you been angered because of things that happened that were outside of your control?NeverAlmost NeverSometimesFairly OftenVery Often12. In the last month, how often have you found yourself thinking about things that you have to accomplish?NeverAlmost NeverSometimesFairly OftenVery Often13. In the last month, how often have you been able to control the way you spend your time?NeverAlmost NeverSometimesFairly OftenVery Often14. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?NeverAlmost NeverSometimesFairly OftenVery OftenDate Date Format: MM slash DD slash YYYY My Score:OtherOther 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 informationPlease "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/documentsCommentsThis 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 allSeveral daysOver half the daysNearly every day2. Over the last 2 weeks, how often have you not being able to stop or control worrying?Not at allSeveral daysOver half the daysNearly every day3. Over the last 2 weeks, how often have you been worrying too much about different things?Not at allSeveral daysOver half the daysNearly every day4. Over the last 2 weeks, how often have you had trouble relaxing?Not at allSeveral daysOver half the daysNearly every day5. Over the last 2 weeks, how often have you been so restless that it's hard to sit still?Not at allSeveral daysOver half the daysNearly every day6. Over the last 2 weeks, how often have you been easily annoyed or irritable?Not at allSeveral daysOver half the daysNearly every day7. Over the last 2 weeks, how often have you been feeling afraid as if something awful might happenNot at allSeveral daysOver half the daysNearly every dayDate Date Format: MM slash DD slash YYYY My Score:OtherOther 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 informationPlease "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]EmailThis 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 allSeveral daysOver half the daysNearly every day2. Over the last 2 weeks have you been bothered by feeling down, depressed, or hopeless?Not at allSeveral daysOver half the daysNearly every day3. Over the last 2 weeks have you been bothered by trouble falling asleep, or staying asleep, or sleeping too much?Not at allSeveral daysOver half the daysNearly every day4. Over the last 2 weeks have you been bothered by feeling tired or having little energy?Not at allSeveral daysOver half the daysNearly every day5. Over the last 2 weeks have you been bothered by poor appetite or overeating?Not at allSeveral daysOver half the daysNearly every day6. 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 allSeveral daysOver half the daysNearly every day7. Over the last 2 weeks have you been bothered by trouble concentrating on things, such as reading the newspaper or watching television?Not at allSeveral daysOver half the daysNearly every day8. 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 allSeveral daysOver half the daysNearly every day9. 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 allSeveral daysOver half the daysNearly every dayDate Date Format: MM slash DD slash YYYY My Score:OtherOther 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 informationPlease "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 PhoneThis 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?NoYes2. Are you having money troubles because of drinking or using?NoYes3. Do you ever stay home from work because of drinking or using?NoYes4. Is drinking or using causing trouble in your family?NoYes5. Is drinking or using giving you a bad reputation?NoYes6. Have you lost a job or a business because of drinking or using?NoYes7. Do you drink or use to escape your problems?NoYes8. Do you drink or use when you are alone?NoYes9. Do you have blackouts? (Loss of memory for events that happened or of actions you performed while drinking or using?)NoYes10. Do you feel remorse after drinking or using?NoYes11. Do you need a drink at a definite time every day?NoYes12. Do you drink in the morning?NoYes13. Have you ever been in a hospital because of drinking or using?NoYes14. Has a doctor ever treated you for your drinking or using?NoYes15. Do you drink or use too much at the wrong time?NoYes16. Do you make promises to yourself or others about your drinking or using?NoYes17. Do you have to keep on drinking or using once you have started?NoYes18. Is drinking or using making it hard for you to sleep?NoYes19. Have you had an accident because of drinking or using?NoYes20. Do you drink or use to relieve the painfulness of living?NoYes21. Do you have trouble disposing of cans or bottles?NoYes22. Are you less particular about people you are with and the places you go when you are drinking or using?NoYes23. Have you been arrested more than once for drunk driving or driving under the influence of drugs?NoYes24. Has drinking or using affected your health?NoYesMy Score:Date Date Format: MM slash DD slash YYYY OtherOther 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 informationPlease "take a knee" if you feel you might need to!Source: https://www.cottonwooddetucson.com/drug-alcohol-self-assessmentCommentsThis field is for validation purposes and should be left unchanged. Trauma Scene Questionnaire Trauma Screening Questionnaire (TSQ) 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. Upsetting thoughts or memories about the event that have come into your mind against your will?NoYes2. Upsetting dreams about event?NoYes3. Acting or feeling as though the event were happening again?NoYes4. Feeling upset be reminders of the event?NoYes5. Bodily reactions (such as fast heartbeat, stomach churning, sweatiness, dizziness) when reminded of the event?NoYes6. Difficulty falling or staying asleep?NoYes7. Irratability or outbursts of anger?NoYes8. Difficulty concentrating?NoYes9. Heightened awareness of potential dangers to yourself and others?NoYes10. Being jumpy or being startled at something unexpected?NoYesMy Score:Date Date Format: MM slash DD slash YYYY OtherOther 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 informationPlease "take a knee" if you feel you might need to!EmailThis field is for validation purposes and should be left unchanged. More ratings to be added soon!