NuStart Coaching Program Questionnaire

Name:*

First Last

E-mail:*

Cell Phone Number:*

Employer/Organization:*

Patient Health Questionnaire – 9 (PHQ – 9)
Over the last 2 weeks, how often have you been bothered by any of the following problems (please indicate your answers below)?

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 so fidgety or restless that you have been moving around a lot more than usual*

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

PHQ-9 Score

PHQ-9 Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

Wellbeing Survey
For each of the following questions, select the answer that best describes how you have felt over the last 3 months:

In general, how have you felt about YOURSELF in the past 3 months?*

In general, how have you felt about your HEALTH in the past 3 months?*

For each of the following statements, indicate how you have felt most of the time over the last 3 months:

…I have felt sure about myself*

…I felt liked by others*

…I liked who I am*

…I felt I am successful*

…I felt I have good self-esteem*

…I felt I am satisfied with myself*

…I felt I would not change myself*

…I felt I have a number of good qualities*

…I fell asleep easily*

…I slept through the night*

…I awake rested*

…I felt happy*

…I felt hopeful about the future*

…I felt in control of my life*

…I felt I enjoyed my life*

Wellness Score

How satisfied are you with this program?*

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