AOQ Form Adult Outcomes Questionnaire 1.4 Please enable JavaScript in your browser to complete this form.Name *FirstLastMedical Record # *Date *PART A - Over the last two weeks, how often have you been bothered by any of the following problems? A1. Little interest or pleasure in doing things *Not at all - 0Several days - 1 More than half the days - 2Nearly every day - 3A2. Feeling down depressed or hopeless *Not at all - 0Several days - 1 More than half the days - 2Nearly every day - 3A3. Trouble falling or staying asleep, or sleeping too much *Not at all - 0Several days - 1 More than half the days - 2Nearly every day - 3A4. Feeling tired or having little energy *Not at all - 0Several days - 1 More than half the days - 2Nearly every day - 3A5. Poor appetite or overeating *Not at all - 0Several days - 1 More than half the days - 2Nearly every day - 3A6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down *Not at all - 0Several days - 1 More than half the days - 2Nearly every day - 3A7. Trouble concentrating on things, such as reading the newspaper or watching television *Not at all - 0Several days - 1 More than half the days - 2Nearly every day - 3A8. Moving 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 all - 0Several days - 1 More than half the days - 2Nearly every day - 3A9. Thoughts that you would be better off dead, or of hurting yourself in some way *Not at all - 0Several days - 1 More than half the days - 2Nearly every day - 3PART B - Over the last two weeks, how often have you been bothered by any of the following problems? (copy)B10. Feeling nervous, anxious or on edge *Not at all - 0Several days - 1 More than half the days - 2Nearly every day - 3B11. Not being able to stop or control worrying *Not at all - 0Several days - 1 More than half the days - 2Nearly every day - 3B12. Feeling unproductive at work or other daily activities *Not at all - 0Several days - 1 More than half the days - 2Nearly every day - 3B13. Having trouble focusing on achieving your goals *Not at all - 0Several days - 1 More than half the days - 2Nearly every day - 3PART F - If you have had a visit in the Mental Health Department, mark the number that BEST matches your feelings about your most recent visit. F1. In the session, we discuss the things that are most important to me. *Only a little or not at all - 0Sometimes - 1Quite a bit - 2Totally - 3F2. I feel understood and respected by my clinician. *Only a little or not at all - 0Sometimes - 1Quite a bit - 2Totally - 3F3. I understand and agree with my treatment plan. *Only a little or not at all - 0Sometimes - 1Quite a bit - 2Totally - 3Send to Susan
