Self referral WelcomePlease complete the following scales by selecting the most appropriate answer. Do not worry about scoring them, simply choose the option which applies to you the most.Emotional Difficulties *0 - Not at all12345678910 - As badly as I can imagineHow much have your problems distressed you in the last 2 weeks.Feeling strong and able to cope with life’s demands *0 - Not at all12345678910 - As strong as I can imagineHow strong have you felt within yourself in the last 2 weeks.Work and Social Adjustent ScaleRate each of the following questions on a scale of 0 (no impairment at all) to 8 (very severe impairment).Work *0 - Not at all12 - Slightly34 - Definitely56 - Markedly78 - Very severelyN/AIf you are retired or choose not to have a job for reasons unrelated to your problem, please tick N/A (not applicable)Home Management *0 - Not at all12 - Slightly34 - Definitely56 - Markedly78 - Very severelyN/ACleaning, tidying, shopping, cooking, looking after home/children, paying bills etc.Social Leisure Activities *0 - Not at all12 - Slightly34 - Definitely56 - Markedly78 - Very severelyN/AWith other people, e.g. parties, pubs, outings, entertaining etc.Private Leisure Activities *0 - Not at all12 - Slightly34 - Definitely56 - Markedly78 - Very severelyN/ADone alone, e.g. reading, gardening, sewing, hobbies, walking etc.Family and Relationships *0 - Not at all12 - Slightly34 - Definitely56 - Markedly78 - Very severelyN/AForm and maintain close relationships with others including the people that I live with.Mundt JC, Marks IM, Shear MK, Greist JH. The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br J Psychiatry. 2002 May;180:461-4. doi: 10.1192/bjp.180.5.461. PMID: 11983645.Over the Last Week...Important - Please Read This First This form has 10 statements about how you have been OVER THE LAST WEEK. Please read each statement and think how often you felt that way last week. Then select the choice which is closest to this.I have felt tense, anxious or nervous *Not at allOnly occasionallySometimesOftenMost or all the timeI have felt I have someone to turn to for support when needed *Not at allOnly occasionallySometimesOftenMost or all the timeI have felt able to cope when things go wrong *Not at allOnly occasionallySometimesOftenMost or all the timeTalking to people has felt too much for me *Not at allOnly occasionallySometimesOftenMost or all the timeI have felt panic or terror *Not at allOnly occasionallySometimesOftenMost or all the timeI made plans to end my life *Not at allOnly occasionallySometimesOftenMost or all the timeI have had difficulty getting to sleep or staying asleep *Not at allOnly occasionallySometimesOftenMost or all the timeI have felt despairing or hopeless *Not at allOnly occasionallySometimesOftenMost or all the timeI have felt unhappy *Not at allOnly occasionallySometimesOftenMost or all the timeUnwanted images or memories have been distressing me *Not at allOnly occasionallySometimesOftenMost or all the time Barkham, M., Bewick, B., Mullin, T., Gilbody, S., Connell, J., Cahill, J., Mellor-Clark, J., Richards, D., Unsworth, G. & Evans, C. (2012). The CORE-10: A short measure of psychological distress for routine use in the psychological therapies. Counselling and Psychotherapy Research, 1–11.Self-esteemBelow is a list of statements dealing with your general feelings about yourself.I feel that I am a person of worth, at least on an equal plane with others *Strongly AgreeAgreeDisagreeStrongly DisagreeI feel that I have a number of good qualities *Strongly AgreeAgreeDisagreeStrongly DisagreeAll in all, I am inclined to feel that I am a failure *Strongly AgreeAgreeDisagreeStrongly DisagreeI am able to do things as well as most other people *Strongly AgreeAgreeDisagreeStrongly DisagreeI feel I do not have much to be proud of *Strongly AgreeAgreeDisagreeStrongly DisagreeI take a positive attitude toward myself *Strongly AgreeAgreeDisagreeStrongly DisagreeOn the whole, I am satisfied with myself *Strongly AgreeAgreeDisagreeStrongly DisagreeI wish I could have more respect for myself *Strongly AgreeAgreeDisagreeStrongly DisagreeI certainly feel useless at times *Strongly AgreeAgreeDisagreeStrongly DisagreeAt times I think I am no good at all *Strongly AgreeAgreeDisagreeStrongly DisagreeRosenberg, M. (1965). Rosenberg Self-Esteem Scale (RSES) [Database record]. APA PsycTests.PHQ-9Over the last 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things *Not at allSeveral daysMore than half the daysNearly every dayFeeling down, depressed, or hopeless *Not at allSeveral daysMore than half the daysNearly every dayTrouble falling or staying asleep, or sleeping too much *Not at allSeveral daysMore than half the daysNearly every dayFeeling tired or having little energy *Not at allSeveral daysMore than half the daysNearly every dayPoor appetite or overeating *Not at allSeveral daysMore than half the daysNearly every dayFeeling bad about yourself — or that you are a failure or have let yourself or your family down *Not at allSeveral daysMore than half the daysNearly every dayTrouble concentrating on things, such as reading the newspaper or watching television *Not at allSeveral daysMore than half the daysNearly every dayMoving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual *Not at allSeveral daysMore than half the daysNearly every dayThoughts that you would be better off dead or of hurting yourself in some way *Not at allSeveral daysMore than half the daysNearly every dayKroenke, K., Spitzer, R. L., & Williams, J. B. W. (1999). Patient Health Questionnaire-9 (PHQ-9) [Database record].The Last Two Weeks ContinuedOver the last 2 weeks, how often have you been bothered by any of the following problems? Feeling nervous, anxious or on edge *Not at allSeveral daysMore than half the daysNearly every dayNot being able to stop or control worrying *Not at allSeveral daysMore than half the daysNearly every dayWorrying too much about different things *Not at allSeveral daysMore than half the daysNearly every dayTrouble relaxing *Not at allSeveral daysMore than half the daysNearly every dayBeing so restless that it is hard to sit still *Not at allSeveral daysMore than half the daysNearly every dayBecoming easily annoyed or irritable *Not at allSeveral daysMore than half the daysNearly every dayFeeling afraid as if something awful might happen *Not at allSeveral daysMore than half the daysNearly every daySpitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006 May 22;166(10):1092-7.Do you struggle with eating difficutlies? *NoYesEating questionnaire - EDEQInstructions: The following questions are concerned with the past four weeks (28 days) only. Please read each question carefully. Please answer all the questions. Thank you. Questions 1 to 12: Please choose the appropriate score. Remember that the questions only refer to the past four weeks (28 days) only.1. Have you been deliberately trying to limit the amount of food you eat to influence your shape or weight (whether or not you have succeeded)? *No days1-5 days6-12 days13-15 days16-22 days23-27 daysEvery day1. Have you been deliberately trying to limit the amount of food you eat to influence your shape or weight (whether or not you have succeeded)? *2. Have you gone for longs periods of time (8 waking hours or more) without eating anything at all in order to influence your shape or weight? *No days1-5 days6-12 days13-15 days16-22 days23-27 daysEvery day3. Have you tried to exclude from your diet any foods that you like in order to influence your shape or weight (whether or not you have succeeded)? *No days1-5 days6-12 days13-15 days16-22 days23-27 daysEvery day3. Have you tried to exclude from your diet any foods that you like in order to influence your shape or weight (whether or not you have succeeded)? *4. Have you tried to follow definite rules regarding your eating (for example, a calorie limit) in order to influence your shape and weight (whether or not you have succeeded)? *No days1-5 days6-12 days13-15 days16-22 days23-27 daysEvery day4. Have you tried to follow definite rules regarding your eating (for example, a calorie limit) in order to influence your shape and weight (whether or not you have succeeded)? *5. Have you had a definite desire to have an empty stomach with the aim of influencing your shape or weight? *No days1-5 days6-12 days13-15 days16-22 days23-27 daysEvery day5. Have you had a definite desire to have an empty stomach with the aim of influencing your shape or weight? *6. Have you had a definite desire to have a totally flat stomach? *No days1-5 days6-12 days13-15 days16-22 days23-27 daysEvery day6. Have you had a definite desire to have a totally flat stomach? *7. Has thinking about food, eating or calories made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)? *No days1-5 days6-12 days13-15 days16-22 days23-27 daysEvery day7. Has thinking about food, eating or calories made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)? *8. Has thinking about shape and weight made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)? *No days1-5 days6-12 days13-15 days16-22 days23-27 daysEvery day8. Has thinking about shape and weight made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)? *9. Have you had a definite fear of losing control over eating? *No days1-5 days6-12 days13-15 days16-22 days23-27 daysEvery day10. Have you had a definite fear that you might gain weight? *No days1-5 days6-12 days13-15 days16-22 days23-27 daysEvery day11. Have you felt fat? *No days1-5 days6-12 days13-15 days16-22 days23-27 daysEvery day12. Have you had a strong desire to lose weight? *No days1-5 days6-12 days13-15 days16-22 days23-27 daysEvery dayQuestions 13-18:Please enter the appropriate number in the boxes provided. Remember that the questions only refer to the past four weeks (28 days). 13. Over the past 28 days, how many times have you eaten what other people would regard as unusually large amounts of food (given the circumstances)? *13. Over the past 28 days, how many times have you eaten what other people would regard as unusually large amounts of food (given the circumstances)? *14. On how many of these times did you have a sense of having lost control over your eating (at the time you were eating)? *14. On how many of these times did you have a sense of having lost control over your eating (at the time you were eating)? *15. Over the past 28 days, on how many DAYS have such episodes of overeating occurred (i.e. you have eaten unusually large amounts of food and have had a sense of loss of control at the time)? *15. Over the past 28 days, on how many DAYS have such episodes of overeating occurred (i.e. you have eaten unusually large amounts of food and have had a sense of loss of control at the time)? *16. Over the past 28 days, how many times have you made yourself sick (vomit) as a means of controlling your shape and weight? *16. Over the past 28 days, how many times have you made yourself sick (vomit) as a means of controlling your shape and weight? *17. Over the past 28 days, how many times have you taken laxatives as a means of controlling your shape or weight? *17. Over the past 28 days, how many times have you taken laxatives as a means of controlling your shape or weight? *18. Over the past 28 days, how many times have you exercised in a “driven” or “compulsive” way as a means of controlling your weight, shape or amount of fat, or to burn calories? *18. Over the past 28 days, how many times have you exercised in a “driven” or “compulsive” way as a means of controlling your weight, shape or amount of fat, or to burn calories? *Questions 19-21:Please select the appropriate number. Please note that for these questions the term “binge eating” means eating what others would regards as an unusual large amount of food for the circumstances, accompanied by a sense of having lost control over eating.19. Over the last 28 days, on how many days have you eaten in secret (i.e. furtively)? *No days1-5 days6-12 days13-15 days16-22 days23-27 daysEvery dayDo not count episodes of binge eating20. On what proportion of the times that you have eaten have you felt guilty (felt that you’ve done wrong) because of its effect on your shape and weight? *No days1-5 days6-12 days13-15 days16-22 days23-27 daysEvery dayDo not count episodes of binge eating21. Over the past 28 days, how concerned have you been about other people seeing you eat? *No days1-5 days6-12 days13-15 days16-22 days23-27 daysEvery dayDo not count episodes of binge eatingQuestions 22-28:Please choose the appropriate number. Remember that the questions only refer to the past four weeks (28 days). 22. Has your weight influenced how you think about (judge) yourself as a person? *0 - Not at all12 - Slightly34 - Definitely56 - Markedly22. Has your weight influenced how you think about (judge) yourself as a person? *23. Has your shape influenced how you think about (judge) yourself as a person? *0 - Not at all12 - Slightly34 - Definitely56 - Markedly23. Has your shape influenced how you think about (judge) yourself as a person? *24. How much would It have upset you if you had been asked to weigh yourself once a week (no more, or less, often) for the next four weeks? *0 - Not at all12 - Slightly34 - Definitely56 - Markedly25. How dissatisfied have you been with your weight? *0 - Not at all12 - Slightly34 - Definitely56 - Markedly25. How dissatisfied have you been with your weight? *26. How dissatisfied have you been with your shape? *0 - Not at all12 - Slightly34 - Definitely56 - Markedly26. How dissatisfied have you been with your shape? *27. How uncomfortable have you felt seeing your body (for example, seeing your shape in the mirror, in a shop window reflection, while undressing or taking a bath or shower)? *0 - Not at all12 - Slightly34 - Definitely56 - Markedly28. How uncomfortable have you felt about others seeing your shape or figure (for example, in communal changing rooms, when swimming, or wearing tight clothes)? *0 - Not at all12 - Slightly34 - Definitely56 - MarkedlyWhat is your weight at present? (Please give your best estimate). *0 / 10What is your height? (Please give your best estimate). *0 / 6Were you *Assigned male at birth (AMAB)Assigned female at birth (AFAB)?Over the past three-to-four months have you missed any menstrual periods? *NoYesHow many menstrual periods have you missed? *14Have you been taking the “pill”? *NoYesFairburn, C. G., & Beglin, S. J. (1994). Eating Disorder Examination Questionnaire (EDE-Q) [Database record]. PsycTESTS. 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