GADQ
Your birthdate and date of your first DBTCSD therapy session are needed for us to identify your data while keeping it anonymous to others. Your data will be transmitted securely as scrambled numbers without any text labels.
Birthday
Jan 1
Feb 2
Mar 3
Apr 4
May 5
Jun 6
July 7
Aug 8
Sep 9
Oct 10
Nov 11
Dec 12
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
year
Name of therapist
Gutierrez
Dahlin
Langlois
Jay Weingarten
Brown
Contreras
Tuesday Group
Wednesday Group
Thursday Group
Other
(primary therapist)
Filled out by
client
parent
other
No
Yes
Do you experience excessive worry?
No
Yes
Is your worry excessive in intensity, frequency, or amount of distress it causes?
No
Yes
Do you find it difficult to control your worry (or stop worrying) once it starts?
No
Yes
Do you worry excessively and uncontrollably about minor things such as being late for an appointment, minor repairs, homework, etc.?
No
Yes
During the last six months, have you often been bothered by excessive and uncontrollable worries more days than not?
IF YES, CONTINUE. IF NO, DISCONTINUE.
No
Yes
During the last six months, have you often been bothered by restlessness or feeling keyed up or on edge more days than not?
No
Yes
During the last six months, have you often been bothered by difficulty falling/staying asleep or restless/unsatisfying sleep more days than not?
No
Yes
During the last six months, have you often been bothered by difficulty concentrating or your mind going blank more days than not?
No
Yes
During the last six months, have you often been bothered by irritability more days than not?
No
Yes
During the last six months, have you often been bothered by being easily fatigued more days than not?
No
Yes
During the last six months, have you often been bothered by muscle tension more days than not?
0 - Not at All
1
2 - Mildly
3
4 - Moderately
5
6 - Severely
7
8 - Very Severely
How much do worry and physical symptoms interfere with your life, work, social activities, family, etc.?
0 - No Distress
1
2 - Mild Distress
3
4 - Moderate Distress
5
6 - Severe Distress
7
8 - Very Severe Distress
How much are you bothered by worry and physical symptoms (how much distress does it cause you)?
MC
PB
AG
JL
KD
MM
ALB
MZB