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We’d like to ask you a few more questions.
This short survey will only take a minute to complete and will help us monitor how you are doing. If you are a caregiver, please answer the questions as they relate to the Fidelis Care member identified below.
Name
First
Last
We would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today. In the past 7 days:
I have been able to laugh and see the funny side of things
*
As much as I always could
Not quite so much now
Definitely not so much now
Not at all
I have looked forward with enjoyment to things
*
As much as I ever did
Rather less than I used to
Definitely less than I used to
Hardly at all
I have blamed myself unnecessarily when things went wrong
*
No, never
Not very often
Yes, some of the time
Yes, most of the time
I have been anxious or worried for no good reason
*
No, not at all
Hardly ever
Yes, sometimes
Yes, very often
I have felt scared or panicky for no very good reason
*
No, not at all
No, not much
Yes, sometimes
Yes, quite a lot
Things have been getting on top of me
*
No, I have been coping as well as ever
No, most of the time I have coped quite well
Yes, sometimes I haven’t been coping as well as usual
Yes, most of the time I haven’t been able to cope at all
I have been so unhappy that I have had difficulty sleeping
*
No, not at all
Not very often
Yes, sometimes
Yes, most of the time
I have felt sad or miserable
*
No, not at all
Not very often
Yes, sometimes
Yes, most of the time
I have been so unhappy that I have been crying
*
No, never
Only occasionally
Yes, quite often
Yes, most of the time
The thought of harming myself has occurred to me
*
Never
Hardly ever
Sometimes
Yes, quite often
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Call Care Coordinator
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Harm Self
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status
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