Wellbeing Tracker

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

1. Mood Tracker

Over the last two weeks how often have you been bothered by any of the following problems. Mark your answers based on the following scale:
(0 = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every day)

Little interest or pleasure in doing things

Feeling down, depressed or hopeless

Trouble falling or staying asleep or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself or that you are a failure or have let yourself or your family down

Trouble concentrating on things such as reading the newspaper or watching television

Moving or speaking so slowly that other people could have noticed? Or the opposite; being fidgety or restless that you have been moving around a lot more than usual

Thoughts that you would be better off dead or thoughts of hurting yourself in some way

2. Anxiety Tracker

Over the last two weeks how often have you been bothered by any of the following problems. Mark your answers based on the following scale:
(0 = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every day)

Feeling nervous, anxious or on edge

Not being able to stop or control worrying

Worrying too much about different things

Trouble relaxing

Being so restless that it is hard to sit still

Becoming easily annoyed or irritable

Feeling afraid as if something awful might happen

3. Impact Tracker

People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each statement below and determine on the scale provided how much your problem impairs your ability to carry out the activity.
(0 = not at all, 2 = slightly, 4 = definitely, 6 = markedly, 8 = very severely)

Work if retired or choose not to have a job for reasons unrelated to your problem, please tick N/A

At Home cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc.

Social & Leisure with other people, eg. parties, pubs, outings, entertaining etc.

Private Leisure done alone, eg. reading, gardening, sewing, hobbies, walking etc.

Relationships form and maintain close relationships with others including the people I live with

4. Avoidance Tracker

Choose a number from the scales below to show how much you would avoid each of the situations or objects listed.
(0 = would not avoid it, 2 = slightly avoid, 4 = definitely avoid, 6 = markedly avoid, 8 = always avoid)

Social Situations due to a fear of being embarrassed or making a fool of myself

Distress Situations certain situations because of a fear of having a panic attack or other distressing symptoms such as loss of bladder control, vomiting or dizziness

External Situations certain situation because of a fear of particular objects or activities such as animals, heights, seeing blood, being in confined spaces, driving or flying

5. Employment Tracker

Please indicate which one of the following options best describes your current status.

Are you currently receiving statutory sick pay (SSP)?

If you are employed, what is your current Employment Attendance Status?

What is the average number of hours you typically work in a week?

Are you currently receiving benefits?

Are you receiving Jobseekers Allowance?

Are you receiving Employment and Support Allowance?

Are you receiving Universal Credit?

Do you currently receive a Personal Independence Payment?

Are you currently receiving any other benefits that are not listed above?

6. Medication Tracker

Are you taking any prescribed medication for your mood or anxiety?

Your full name

Title of upcoming course

---CBT for InsomniaDoing More Feeling BetterFacing Your FearsIntroduction to MindfulnessOnline Mindfulness for WellbeingIntroduction to WellbeingManaging WorryUnderstanding Your Mental HealthPositive WellbeingPsychology of EmotionsRetraining Your ThinkingSilvercloud OnlineStaying WellStress ControlSuccessful StudyWellbeing in the WorkplaceEmployment Support WorkshopOther

Date attended course

---12345678910111213141516171819202122232425262728293031

---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Email

Contact telephone number

Date of birth

---12345678910111213141516171819202122232425262728293031

---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

---201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900

My GP Surgery is in:

---NorfolkSuffolkSuffolk Waveney

Questionnaires submitted from this page are monitored during normal office hours Monday to Friday (except bank holidays) and this form should not be used in an emergency. If you are feeling at risk to yourself or others please contact your GP urgently or you can dial the NHS 111 helpline for further advice on what to do at this time. Alternatively you can telephone the Samaritans 24 hours a day on 116 123.