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Inpatient Acute/Gen. Stabilization Track

Patient ID:

Part 1: BASIS - 24
Part 2: Coping Self Efficacy
Part 3: HAM - D (self-assessment)

During the PAST WEEK, how much difficulty did you have managing your day-to-day life?

(0) No Difficulty (1) A Little Difficulty (2) Moderate Difficulty (3) Quite A Bit of Difficulty (4) Extreme Difficulty

During the PAST WEEK, how much difficulty did you have coping with problems in your life?

(0) No Difficulty (1) A Little Difficulty (2) Moderate Difficulty (3) Quite A Bit of Difficulty (4) Extreme Difficulty

During the PAST WEEK, how much difficulty did you have concentrating?

(0) No Difficulty (1) A Little Difficulty (2) Moderate Difficulty (3) Quite A Bit of Difficulty (4) Extreme Difficulty

During the PAST WEEK, how much of the time did you get along with people in your family?

(4) None of the Time (3) A Little of the Time (2) Half of the Time (1) Most of the Time (0) All of the Time

During the PAST WEEK, how much of the time did you get along with people outside your family?

(4) None of the Time (3) A Little of the Time (2) Half of the Time (1) Most of the Time (0) All of the Time

During the PAST WEEK, how much of the time did you get along well in social situations?

(4) None of the Time (3) A Little of the Time (2) Half of the Time (1) Most of the Time (0) All of the Time

During the PAST WEEK, how much of the time did you feel close to another person?

(4) None of the Time (3) A Little of the Time (2) Half of the Time (1) Most of the Time (0) All of the Time

During the PAST WEEK, how much of the time did you feel like you had someone to turn to if you needed help?

(4) None of the Time (3) A Little of the Time (2) Half of the Time (1) Most of the Time (0) All of the Time

During the PAST WEEK, how much of the time did you feel confident in yourself?

(4) None of the Time (3) A Little of the Time (2) Half of the Time (1) Most of the Time (0) All of the Time

During the PAST WEEK, how much of the time did you feel sad or depressed?

(0) None of the Time (1) A Little of the Time (2) Half of the Time (3) Most of the Time (4) All of the Time

During the PAST WEEK, how much of the time did you think about ending your life?

(0) None of the Time (1) A Little of the Time (2) Half of the Time (3) Most of the Time (4) All of the Time

During the PAST WEEK, how much of the time did you feel nervous?

(0) None of the Time (1) A Little of the Time (2) Half of the Time (3) Most of the Time (4) All of the Time

During the PAST WEEK, how often did you have thoughts racing through your head?

(0) Never (1) Rarely (2) Sometimes (3) Often (4) Always

During the PAST WEEK, how often did you think you had special powers?

(0) Never (1) Rarely (2) Sometimes (3) Often (4) Always

During the PAST WEEK, how often did you hear voices or see things?

(0) Never (1) Rarely (2) Sometimes (3) Often (4) Always

During the PAST WEEK, how often did you think people were watching you?

(0) Never (1) Rarely (2) Sometimes (3) Often (4) Always

During the PAST WEEK, how often did you think people were against you?

(0) Never (1) Rarely (2) Sometimes (3) Often (4) Always

During the PAST WEEK, how often did you have mood swings?

(0) Never (1) Rarely (2) Sometimes (3) Often (4) Always

During the PAST WEEK, how often did you feel short-tempered?

(0) Never (1) Rarely (2) Sometimes (3) Often (4) Always

In the PAST WEEK, how often did you think about hurting yourself?

(0) Never (1) Rarely (2) Sometimes (3) Often (4) Always

During the PAST WEEK, how often did you have an urge to drink alcohol or take street drugs?

(0) Never (1) Rarely (2) Sometimes (3) Often (4) Always

During the PAST WEEK, how often did anyone talk to you about your drinking or drug use?

(0) Never (1) Rarely (2) Sometimes (3) Often (4) Always

During the PAST WEEK, how often did you try to hide your drinking or drug use?

(0) Never (1) Rarely (2) Sometimes (3) Often (4) Always

During the PAST WEEK, how often did you have problems with your drinking or drug use?

(0) Never (1) Rarely (2) Sometimes (3) Often (4) Always

When things are not going well for you, how confident are you that you can keep from getting down in the dumps? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can talk positively to yourself? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can sort out what can be changed, and what cannot be changed? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can get emotional support from friends and family? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can find solutions to your most difficult problems? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can break an upsetting problem down into smaller parts? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can leave options open when things get stressful? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can make a plan of action and follow it when confronted with a problem? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can develop new hobbies or recreations? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can take your mind off unpleasant thoughts? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can look for something good in a negative situation? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can keep from feeling sad? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can see things from the other person's point of view during a heated argument? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can try other solutions to your problems if your first solutions don't work? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can stop yourself from being upset by unpleasant thoughts? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can make new friends? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can get friends to help with the things you need? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can do something positive for yourself when you are feeling discouraged? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can make unpleasant thoughts go away? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can think about one part of the problem at a time? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can visualize a pleasant activity or place? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can keep yourself from feeling lonely? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can pray or meditate? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can get emotional support from community organizations or resources? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can stand your ground and fight for what you want? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

When things are not going well for you, how confident are you that you can resist the impulse to act hastily when under pressure? (Scale of 0-10, with 0 being "Cannot do at all" and 10 being "Certain I can do")

0 - Cannot do at all 1 2 3 4 5 6 7 8 9 10 - Certain I can do

Please choose one statement that best describes how you have been feeling over the past three days (including today).

(0) I have been in my usual good mood. (1) I have felt a little more sad than usual. (2) I have been clearly more sad than usual, but haven't felt helpless or hopeless. (3) I have been so gloomy that I briefly have felt overpowered by hopelessness. (4) I have been so low in my moods that everything seems dark and hopeless.

Please choose one statement that best describes how you have been feeling over the past three days (including today).

(0) I have been quite satisfied with myself. (1) I have been a little more self-critical than usual with a tendency to feel less worthy than others. (2) I have been brooding over my failures in the past. (3) I have been plagued with distressing guilt feelings. (4) I have been convinced that my current condition is a punishment.

Please choose one statement that best describes how you have been feeling over the past three days (including today).

(0) My daily activities have been as usual. (1) I have been less interested in my usual activities. (2) I have felt that I have had difficulty performing my daily activities, but I was still able to perform them with great effort. (3) I have had difficulty performing even simple routine activities. (4) I have not been able to do any of the most simple day-to-day activities without help...

Please choose one statement that best describes how you have been feeling over the past three days (including today).

(0) I have felt neither restless nor slowed down. (1) Have felt a little slowed down. (2) I have felt rather slowed down or have been talking a little less than usual. (3) I have felt clearly slowed down or subdued or have talked much less than usual. (4) I have hardly been talking at all or felt extremely slowed down all the time.

Please choose one statement that best describes how you have been feeling over the past three days (including today).

(0) I have been calm and relaxed. (1) I have felt a little more tense or insecure than usual. (2) I have been clearly more worries or tense than usual, but have not felt that I lost control. (3) I have been so tense or worried that I have briefly felt close to panic. (4) I have had episodes where I was overwhelmed by panic.

Please choose one statement that best describes how you have been feeling over the past three days (including today).

(0) I have been as active and have had as much energy as usual. (1) I have felt rather low in energy or physically unwell with some bodily pains. (2) I have felt very low in energy or had bodily pains.

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