Cape 15 Questionnaire

    Please complete all the following sections including your name, date of birth and contact details. This information will treated with confidence in accordance with the Data Protection Act 1998 and will be used to help you measure your progress whilst accessing our services.

    Instructions for completing the questionnaire

    This questionnaire includes 15 questions, they all refer to the last 3 months. There are two parts for each question, the first part is about some experiences and thoughts you may have had, and the second part is about how distressed these experiences made you feel.

    For each question, please tick the box that is most true for you. If you answered 'Never' to the first part of the question, you need to answer NA to the second part.

    1. In the last 3 months, have you felt as if people seem to drop hints about you or say things with a double meaning?.NeversometimesOftenNearly always

    2. How Distressed are you by this experience? NANot distressedA bit distressedQuite distressedVery distressed

    3. In the last 3 months, have you felt as if some people are not what they seem to be? NeverSometimesOftenNearly always

    4. How Distressed are you by this experience? NANot distressedA bit distressedQuite distressedVery distressed

    5. In the last 3 months, have you felt you are being persecuted in anyway? NeverSometimesOftenNearly always

    6. How Distressed are you by this experience? NANot distressedA bit distressedQuite distressedVery distressed

    7. In the last 3 months, have you felt there is a conspiracy against you? NeverSometimesOftenNearly always

    8. How Distressed are you by this experience? NANot distresseda bit distressedQuite distressedVery distressed

    9. In the last 3 months, have you felt as if electrical devices such as computers can influence the way you think? NeverSometimesOftenNearly always

    10. How Distressed are you by this experience? NANot distresseda bit distressedQuite distressedVery distressed

    11. In the last 3 months, have you felt that people look at you oddly because of your appearance? NeverSometimesOftenNearly always

    12. How Distressed are you by this experience?NANot distresseda bit distressedQuite distressedVery distressed

    13. In the last 3 months, have you felt as if the thoughts in your head are being taken from you? NeverSometimesOftenNearly always

    14. How Distressed are you by this experience?NANot distresseda bit distressedQuite distressedVery distressed

    15. In the last 3 months, have you felt as if the thoughts in your head are not your own? NeverSometimesOftenNearly always

    16. How Distressed are you by this experience?NANot distresseda bit distressedQuite distressedVery distressed

    17. In the last 3 months, have your thoughts been so vivid that you were worried other people would hear them?NeverSometimesOftenNearly always

    18. How Distressed are you by this experience? NANot distresseda bit distressedQuite distressedVery distressed

    19. In the last 3 months, have you heard your thoughts being echoed back to you? NeverSometimesOftenNearly always

    20. How Distressed are you by this experience? NANot distresseda bit distressedQuite distressedVery distressed

    21. In the last 3 months, have you felt as if you are under the control of some force or power other than yourself? NeverSometimesOftenNearly always

    22. How Distressed are you by this experience? NANot distresseda bit distressedQuite distressedVery distressed

    23. In the last 3 months, have you heard voices when you are alone? NeverSometimesOftenNearly always

    24. How Distressed are you by this experience? NANot distresseda bit distressedQuite distressedVery distressed

    25. In the last 3 months, have you heard voices talking to each when you are alone? NeverSometimesOftenNearly always

    26. How Distressed are you by this experience? NANot distresseda bit distressedQuite distressedVery distressed

    27. In the last 3 months, have you felt as if a double has taken place of a family member, friend or acquaintance? NeverSometimesOftenNearly always

    28. How Distressed are you by this experience? NANot distresseda bit distressedQuite distressedVery distressed

    29. In the last 3 months, have you seen objects, people or animals that other people can't see? NeverSometimesOftenNearly always

    30. How Distressed are you by this experience? NANot distresseda bit distressedQuite distressedVery distressed

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    Name

    Email

    Contact Telephone Number

    Date of Birth




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