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During the last 6 months, how often did your family: - 1. Cut back on social activities and entertainment expenses?
During the last 6 months, how often did your family: - 2. Postpone major household purchases?
During the last 6 months, how often did your family: - 3. Postpone clothing purchases?
During the last 6 months, how often did your family: - 4. Change transportation patterns to save money?
During the last 6 months, how often did your family: - 5. Change food shopping or eating habits to save money?
During the last 6 months, how often did your family: - 6. Cut back on charitable contributions?
During the last 6 months, how often did your family: - 7. Reduce household utility use?
During the last 6 months, how often did your family: - 8. Sell some possessions?
During the last 6 months, how often did your family: - 9. Postpone medical care to save money?
During the last 6 months, how often did your family: - 10. Take additional employment to help meet expenses?
Which of the following best described what has happened to your family income during the past 6 months?
Which of the following best describes your family financially at this time?
Directions: Circle or check the responses that are most appropriate for your situation. - What do you feel is the level of your financial stress today?
Using the stair steps below, indicate how satisfied you are with your present financial situation. The “1” at the bottom of the steps represents complete dissatisfaction. The “10” at the top of the stair steps represents complete satisfaction. The more dissatisfied you are, the lower the number you should select. The more satisfied you are, the higher the number you should select. - How satisfied you are with your present financial situation.
How do you feel about your current financial situation?
How often do you worry about being able to meet normal monthly living expenses?
How confident are you that you could find the money to pay for a financial emergency that costs about $1,000?
How often does this happen to you? You want to go out to eat, go to a movie or do something else and don’t go because you can’t afford to?
How frequently do you find yourself just getting by financially and living paycheck to paycheck?
How stressed do you feel about your personal finances in general?
Over the last 2 weeks, how often have you been bothered by the following problems? - 1. Feeling nervous, anxious or on edge
Over the last 2 weeks, how often have you been bothered by the following problems? - 2. Not being able to stop or control worrying
Over the last 2 weeks, how often have you been bothered by the following problems? - 3. Worrying too much about different things
Over the last 2 weeks, how often have you been bothered by the following problems? - 4. Trouble relaxing
Over the last 2 weeks, how often have you been bothered by the following problems? - 5. Being so restless that it is hard to sit still
Over the last 2 weeks, how often have you been bothered by the following problems? - 6. Becoming easily annoyed or irritable
Over the last 2 weeks, how often have you been bothered by the following problems? - 7. Feeling afraid as if something awful might happen
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Over the last 2 weeks, how often have you been bothered by any of the following problems? - 1. Little interest or pleasure in doing things
Over the last 2 weeks, how often have you been bothered by any of the following problems? - 2. Feeling down, depressed, or hopeless
Over the last 2 weeks, how often have you been bothered by any of the following problems? - 3. Trouble falling or staying asleep, or sleeping too much
Over the last 2 weeks, how often have you been bothered by any of the following problems? - 4. Feeling tired or having little energy
Over the last 2 weeks, how often have you been bothered by any of the following problems? - 5. Poor appetite or overeating
Over the last 2 weeks, how often have you been bothered by any of the following problems? - 6. Feeling bad about yourself—or that you are a failure or have let yourself or your family down
Over the last 2 weeks, how often have you been bothered by any of the following problems? - 7. Trouble concentrating on things, such as reading the newspaper or watching television
Over the last 2 weeks, how often have you been bothered by any of the following problems? - 8. 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
Over the last 2 weeks, how often have you been bothered by any of the following problems? - 9. Thoughts that you would be better off dead or of hurting yourself in some way
Over the last week … - 1. I have felt tense, anxious or nervous
Over the last week … - 2. I have felt I have someone to turn to for support when needed
Over the last week … - 3. I have felt OK about myself
Over the last week … - 4. I have felt able to cope when things go wrong
Over the last week … - 5. I have been troubled by aches, pains or other physical problems
Over the last week … - 6. I have been happy with the things I have done
Over the last week … - 7. I have had difficulty getting to sleep or staying asleep
Over the last week … - 8. I have felt warmth or affection for someone
Over the last week … - 9. I have been able to do most things I needed to
Over the last week … - 10. I have felt criticised by other people
Over the last week … - 11. I have felt unhappy
Over the last week … - 12. I have been irritable when with other people
Over the last week … - 13. I have felt optimistic about my future
Over the last week … - 14. I have achieved the things I wanted to
Please circle (select) the number that most accurately represents your level of agreement with each item below: - 1. I am completely unworthy of love.
Please circle (select) the number that most accurately represents your level of agreement with each item below: - 3. I can’t cope with my problems any longer.
Please circle (select) the number that most accurately represents your level of agreement with each item below: - 4. I can’t imagine anyone being able to withstand this kind of pain.
Please circle (select) the number that most accurately represents your level of agreement with each item below: - 6. Suicide is the only way to end this pain.
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