Brief Adult Psychiatric Questionnaire
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Q1. Somatic concern (Degree of concern over present bodily health. Rate the degree to which physical health is perceived as a problem by the patient, whether complaints have a realistic basis or not.)
| Very severe | Not present | Very mild | Mild | Moderate | Severe | Not assessed |
Q2. Anxiety (Worry, fear, or over-concern for present or future. Rate solely on the basis of verbal report of patient’s own subjective experiences. Do not infer anxiety from physical signs or from neurotic defense mechanisms.)
| Not assessed | Not present | Very mild | Mild | Severe | Very severe |
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Q3. EMOTIONAL WITHDRAWAL(Deficiency in relating to the interviewer and to the interviewer situation. Rate only the degree to which the patient gives the impression of failing to be in emotional contact with other people in the interview situation.) (single choice)
| Not assessed | Not present | Very mild | Mild | Severe | Very severe |
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Q4. CONCEPTUAL DISORGANIZATION (Degree to which the thought processes are confused. Rate on the basis of integration of the verbal products of the patient; do not rate on the basis of patient’s subjective impression of his own level of functioning.) (single choice)
| Very severe | Not present | Very mild | Mild | Moderate | Severe | Not assessed |
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Q5. GUILT FEELINGS Over-concern or remorse for past behavior. Rate on the basis of the patient’s subjective experiences of guilt as evidenced by verbal report with appropriate affect (single choice)
| Very severe | Not present | Very mild | Mild | Moderate | Severe | Not assessed |
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Q6. Your name (this will be attached to a person's response when the survey is completed anonymously)
Q7. What’s been happening? Share a relaxed anecdote, case study or recent success.
Q8. Date the activity actually happened
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