Check-in Questionnaire - English

Attachment 5. Client Check-In Questionnaire

Form Approved

OMB No.: 0920-xxxx

Expiration Date: XX/XX/XXXX

Public Reporting burden of this collection of information is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-XXXX).

Note: The Check-In Questionnaire is a subset of items on the Client Questionnaire. It is self-administered by clients (with or without FI present). Questions are meant to determine tenure in their original OUD treatment episode, learn of other treatments that client may have entered, assess client’s recent drug use (prescribed and illicit), check for recent overdoses, ED visits, and hospitalizations, measure current health status, and check for criminal activity. The questionnaire must be self-explanatory as it is self-administered by client with or without FI present.

Programmer Note: At the beginning of the web questionnaire, we will briefly describe the nature of the questions to be asked and include contact information for the National Suicide Prevention Lifeline, which is a national network of local crisis centers that provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week. The telephone number is 1-800-273-TALK.

The Flesh-Kincaid grade reading level is 5.9.

1. Consent (CO)

CO1. Do you acknowledge that you have read, understand, and agree to provide your consent to participate in this survey questionnaire?

1. ☐ Yes, I consent

2. ☐ No, I do not consent

Programmer Note: Include a link to the full text of the informed consent. Label the link:

CO2 Click here if you wish to review the informed consent document.

Programmer Note: If CO1=No, display the message:

CO3 You have indicated that you do not give your consent to participate in this study. If that is correct, confirm that you have withdrawn consent. A member of our research team will contact you to discuss your concerns. Be assured, you always have the right to not answer any question and to withdraw consent any time. If this is not correct, confirm that you do provide consent below and you will be taken to the next question.

1. ☐ Yes, I consent [Return client to CO1]

2. ☐ No, I do not consent [Go to END]

2. Study Site Treatment Status (SS)

Programmer Note: MAT/COUN = type of treatment client is receiving at index facility. Codes are MMT, BUP, NTX, and COUN.

If MMT, use “methadone maintenance therapy”

If BUP, use “buprenorphine (e.g. Suboxone, Probuphine, generic)”

If NTX, use “naltrexone (e.g. Vivitrol, Revia, generic)”

If COUN, use “counseling”

FACILITY = the Short_Name of the index facility

START=the date that index treatment began

INDEX DAYS=days spent in INDEX treatment. If still in INDEX treatment, INDEX DAYS = (today-START). If no longer in INDEX treatment, INDEX DAYS=(date ended treatment (SS3) – START)

Define Index Treatment

BASE: All not previously sent to END.

SS1. You were invited to be in the MAT Study because you were treated for opioid addiction at (FACILITY) using (MAT/COUN) starting (START).

This is your INDEX treatment.

☐ Click here if you did not receive the INDEX treatment described above.

Programmer Note: If ☐ is clicked, display message below and go to END.

There appears to be an error in our records. Please accept our apologies. A member of the research staff will be in contact with you to resolve the error.

Survey Manager Note: Reconcile error and refield the survey.

Dates of Index Treatment

BASE: All not previously sent to END.

SS2. Are you still receiving your INDEX treatment?

Answer NO if:

you stopped going to (FACILITY)

you stopped receiving (MAT/COUN)

you started receiving (MAT/COUN) at a different facility

you still go to (FACILITY) but started receiving a different type of treatment for opioid addiction

1. ☐ Yes

2. ☐ No

BASE: SS2=No

SS3. When did you stop receiving your INDEX treatment? (Enter an approximate date if you are unsure of the exact date.)

_____/_____/_____

Month / Day / Year

Reason to Stop INDEX Treatment

BASE: SS2=No

Programmer note: Do NOT randomly order list.

SS4. Why did you stop receiving your INDEX treatment? (If you have multiple reasons, select the most important reason.)

1. ☐ I completed my INDEX treatment

2. ☐ I voluntarily stopped my INDEX treatment

3. ☐ I continued my [MAT/COUN] treatment at a different facility

4. ☐ I am still receiving treatment for my opioid addiction at (FACILITY), but I am no longer receiving [MAT/COUN]

5. ☐ I was involuntarily discharged from my INDEX treatment program (e.g., for non-compliance, for continued substance use, for violating program rules, for non-payment, etc.)

6. ☐ A different reason/none of the above (specify): _______________

BASE: SS2=No

Programmer note: Randomly order list except none category. 1=checked, 0=not checked

SS5. Here are reasons someone might stop treatment. Did any of these apply to your situation? (Check all that apply.)

1. The program took up too much of my time

2. I couldn’t find or afford daycare for my kids.

3. My insurance ran out.

4. I couldn’t find a way to pay for it.

5. I didn’t have reliable transportation.

6. I got sick and couldn’t make appointments.

7. I didn’t think the treatment was doing any good.

8. I didn’t need the treatment anymore.

9. I didn’t like the people.

10. I relapsed.

11. I went to jail

12. I moved too far away

13. None of these apply

Characteristics of INDEX Treatment

BASE: Ask if R is still enrolled in INDEX treatment (SS2 = Yes) plus the first quex where R says they are no longer enrolled in INDEX treatment (first time SS2 = No).

Programmer note: Do NOT randomly order list. 1=checked, 0=not checked

SS5. While enrolled in INDEX treatment, did you receive: (Check all that apply.)

1. ☐ Methadone

2. ☐ Oral buprenorphine (e.g. Suboxone®, generic)

3. ☐ Implantable or injectable buprenorphine (e.g. Probuphine®, generic)

4. ☐ Oral naltrexone (e.g. Revia®)

5. ☐ Injectable naltrexone (e.g. Vivitrol®)

6. ☐ Other drug (specify) _____________________________

7. ☐ No drug

BASE: Ask if R is still enrolled in INDEX treatment (SS2 = Yes) plus the first quex where R says they are no longer enrolled in INDEX treatment (first time SS2 = No).

Programmer note: Randomly order list (except Other Services and No Other Services). Checked=1, not checked=0.

SS6a-n. While enrolled in INDEX treatment, what other types of services did you receive: (Check all that apply.)

☐ a. Individual counseling

☐ b. Group counseling

☐ c. Other behavioral therapy/counseling

☐ d. Detoxification services

☐ e. Medical services (e.g., physical exams, medication)

☐ f. HIV testing

☐ g. Hepatitis C virus (HCV) testing

☐ h. Laboratory drug testing/ urine testing

☐ i. Case management services (e.g., employment coaching, family services/education, housing services)

☐ j. Peer-to-peer recovery support services (e.g., Peer Navigator)

☐ k. Recovery coach services other than Peer Navigator

☐ l. Training on how to avoid overdosing

☐ m. Training on how to use naloxone

☐ n. Other services

☐ o. No other services

Programmer Note: If “no other services” is checked or question is skipped, display:

You did not check any of the above services. Click here ☐ to go back and enter service(s) or click here ☐ to confirm you received no other services.

3. Peer Navigator/Provider Services (PN)

A “Peer Navigator” (also referred to as a “Peer Provider” or “Peer Support Specialist”) refers to a person who uses their personally lived experiences with addiction and recovery in a treatment setting to promote recovery and resiliency for individuals with the same or similar conditions.

BASE: Ask if R is still enrolled in INDEX treatment (SS2 = Yes) plus the first quex where R says they are no longer enrolled in INDEX treatment (first time SS2 = No).

Programmer Note: The following definition should appear here and be available as clickable definition wherever the term Peer Navigator occurs.

PN1. [SS2=YES: Since you started your INDEX treatment at (FACILITY)/

FIRST TIME SS2=NO: While you were in your INDEX treatment]

were you offered services from a peer navigator?

1. ☐ Yes

2. ☐ No

BASE: If PN1=Yes

PN2. [SS2=YES: Since you began your INDEX treatment,/

[FIRST TIME SS2=No: At any time while you were in your INDEX treatment]

how often did you meet with a peer navigator?

1. ☐ Less than once a month

2. ☐ About once a month

3. ☐ Several times a month

4. ☐ About once a week

5. ☐ Several times a week

6. ☐ I never met with a peer navigator

Programmer note: If R still in INDEX treatment, use “is”. If no longer in INDEX treatment, use “was”.

BASE: If PN1=Yes

PN3. How helpful [SS2=YES:is/SS2=NO:was] your peer navigator to your recovery?

1. ☐ Very helpful

2. ☐ Somewhat helpful

3. ☐ Somewhat unhelpful

4. ☐ Not helpful at all

BASE: If PN2= “I never met with a peer navigator”

Programmer Note: Do NOT randomize list. Checked=1, unchecked=0

PN4. Why did you not meet with a peer navigator? (Check all that apply.)

1. ☐ I did not want the service

2. ☐ I did not think the service was worthwhile for me

3. ☐ I could not afford the service

4. ☐ I will arrange to meet with peer navigator if I ever need their service

5. ☐ I tried to make an appointment but the peer navigator did not have any openings on their schedule

6. ☐ I plan to schedule an appointment soon

7. ☐ I have an appointment scheduled

8. ☐ I had an appointment but the peer navigator didn’t make it

9. ☐ I had another reason that’s not listed above (specify): _____________

BASE: If PN1=Yes or No

Programmer note: Randomize list.

PN5. Whether or not you have ever worked with a peer navigator, we’d like to know if you agree or disagree with the following statements about peer navigators.

1. Peer navigators are helpful

1. ☐ Agree

2. ☐ Neutral or no opinion

3. ☐ Disagree

2. I am uncomfortable sharing my personal life with a peer navigator

3. People I know told me not to work with a peer navigator

4. A peer navigator is not helpful or needed given my situation

5. I would recommend peer navigators to a friend

4. Post-INDEX Treatment (PX)

BASE: If SS2=No

PX1. Since stopping your INDEX treatment, did you start another treatment program for opioid addiction?

Answer YES if:

you started receiving (MAT/COUN) at a different facility

you still go to (FACILITY) but started receiving a different type of treatment for opioid addiction

1. ☐ Yes

2. ☐ No ► GO TO MODULE V. Substance Abuse Treatment

BASE: PX1=Yes

PX2. When did you begin receiving this treatment? (Enter an approximate date if you are unsure of the exact date.)

_____/_____/_____

MM / DD / YY

BASE: PX1=Yes

Programmer note: Randomly order list.

PX3a-p. How important were the following reasons for starting this treatment?

a. I believed I needed treatment

1. ☐ Very important

2. ☐ Somewhat important

3. ☐ Not important

b. My employer believed I had to get treatment

c. My friends/family believed I had to get treatment

d. I failed at getting off drugs on my own

e. I found the type of treatment I wanted

f. There was an opening in the facility I wanted

g. I had transportation I needed

h. I had childcare I needed

i. Treatment was close enough to me

j. Treatment was covered under my health care plan

k. I could afford it

l. I decided I couldn’t handle my addiction on my own

m. I overdosed and was frightened for my life

n. I hit rock bottom

o. I could not find heroin or prescription opioids and was experiencing withdrawal symptoms

p. My doctor recommended that I get treatment

BASE: PX1=Yes

Programmer note: Do NOT randomly order list. Checked=1, not checked=0

PX4a-h. Was your participation in this treatment (Check any that apply):

☐ a. To comply with a court-order

☐ b. To avoid a conviction on a charge(s)

☐ c. To meet a condition of your probation or parole

☐ d. To avoid going to jail or prison

☐ e. To avoid being charged with misdemeanor

☐ f. To avoid being charged with a felony

☐ g. To get your driver’s license back

☐ h. To reduce the points against your license

☐  i. To comply with a child welfare order

☐  j. To help retain or gain custody of children

☐  k.  None of these apply

BASE: PX1=Yes

Programmer note: Do NOT randomly order list. Checked=1, not checked=0

PX5a-h. Who recommended that you go to this facility to get treatment? (Check all that apply.)

☐ a. I picked it myself

☐ b. Friends or family members

☐ c. Alcohol/ drug abuse care provider

☐ d. Primary health care provider

☐ e. School-based counselor

☐ f. Employer

☐ g. Community group (e.g. religious organizations. self-help groups)

☐ h. Court/ criminal justice referral (e.g. police official, judge, prosecutor, probation officer)

☐ i. None of the above

BASE: PX1=Yes

Programmer note: Do NOT randomly order list.

PX6. How would you best describe the place you received this treatment?

1. ☐ Drug rehabilitation center/service

2. ☐ Mental health center or facility

3. ☐ Specialty addiction doctor

4. ☐ General doctor's office or primary care physician

5. ☐ Office-based counseling with psychiatrist, psychologist, or social worker

6. ☐ Other type of place

BASE: PX1=Yes

Programmer note: Do NOT randomly order list.

PX7. This treatment was:

1. ☐ Inpatient

2. ☐ Residential

3. ☐ Intensive outpatient

4. ☐ Outpatient

5. ☐ Other

BASE: PX1=Yes

Programmer note: Do NOT randomly order list. Checked=1, not checked=0

PX8. While enrolled in this treatment, did you receive: (Check all that apply.)

1. ☐ Methadone

2. ☐ Oral buprenorphine (e.g. Suboxone, generic)

3. ☐ Implantable or injectable buprenorphine (e.g. Probuphine, generic)

4. ☐ Oral naltrexone (e.g. Revia)

5. ☐ Injectable naltrexone (e.g. Vivitrol)

6. ☐ Other drug (specify) _____________________________

7. ☐ No drug

BASE: PX1=Yes

Programmer note: Randomly order list (except Other and No Other Services). Checked=1, not checked=0

PX9a-n. While enrolled in this treatment, what other types of services did you receive: (Check all that apply.)

☐ a. Individual counseling

☐ b. Group counseling

☐ c. Other behavioral therapy

☐ d. Detoxification services

☐ e. Medical services (e.g., physical exams, medication)

☐ f. HIV testing

☐ g. Hepatitis C virus (HCV) testing

☐ h. Laboratory drug testing/ urine testing

☐ i. Case management services (e.g., employment coaching, family services/education, housing services)

☐ j. Peer-to-peer recovery support services (e.g., Peer Navigator)

☐ k. Recovery coach services other than Peer Navigator

☐ l. Training on how to avoid overdosing

☐ m. Training on how to use naloxone

☐ n. Other services

☐ o. No other services

Programmer Note: If “No other services” is checked or question is skipped, display: You did not check any of the above services. Click here ☐ to go back and enter service(s) or click here ☐ to confirm you received no other services.

BASE: PX1=Yes

PX10. When you started this treatment, how confident were you that this treatment would be successful?

1. ☐ Not confident

2. ☐ Slightly confident

3. ☐ Moderately confident

4. ☐ Highly confident

BASE: PX1=Yes

PX11. Are you still receiving this treatment at this facility?

1. ☐ Yes

2. ☐ No

BASE: If PX11 = No

PX12. When did you stop receiving treatment at this facility?

MM/DD/YY

BASE: If PX11 = No

Programmer note: DO NOT randomly order list.

PX13. Why did you stop receiving this treatment at this facility?

1. ☐ I completed this treatment program

2. ☐ I voluntarily stopped this treatment

3. ☐ I continued this treatment at a different facility

4. ☐ I am still receiving treatment for my opioid addiction at this facility but I changed treatments

5. ☐ I was involuntarily discharged from this program (e.g., for non-compliance, for continued substance use, for violating program rules, for non-payment, etc.)

6. ☐ A different reason/none of the above (specify): __________

BASE: If PX11 = No

Programmer note: Randomly order list except none category. 1=checked, 0=not checked

PX14. Here are reasons someone might stop treatment. Did any of these apply to your situation? (Check all that apply.)

Programmer note: Use response categories to SS5

BASE: If PX11 = No

PX15. Did you enter treatment for opioid addiction anywhere else after that?

1. ☐ Yes

2. ☐ No

Programmer note: Repeat PX series until R either says they are still obtaining treatment (PX11=Yes) or they say that they have not entered another treatment (PX15=No)

5. Substance Abuse Treatment (SA)

BASE: All clients not previously sent to END

SA1. Over the past 90 days, how many days did you spend receiving your INDEX treatment at (FACILITY)? (Consider all types of treatment received directly at (FACILITY).)

☐ Days (specify) _______

☐ None

SA2. Of those days, how many days included counseling sessions (either individual or group)?

☐ Days (specify) _______

☐ None

6. Opioid Detoxification (DW)

Detoxification/withdrawal services are short-term, medically-supervised process addicted persons go through before they embark on a longer-term drug rehab plan. Detox is the process of getting the opioids out of the addicted person's system and getting him or her physically stable.

BASE: All clients not previously sent to END

DW1. Over the past 90 days, how many times did you go through medically supervised opioid detox?

☐ Times (specify) _______

☐ None

7. Hospital Visits (HS)

BASE: All clients not previously sent to END

HS1. Over the past 90 days, how many nights did you spend in a hospital?

☐ Nights (specify 1-90) _______

☐ None

BASE: If HS1>0

HS1a. How many of those nights were related to injuries or conditions resulting from opioid addiction?

☐ Nights (specify 1-90) _______

☐ None

8. Emergency Department Visits (ED)

BASE: All clients not previously sent to END

ED1. Over the past 90 days, how many times did you go to the Emergency Department?

☐ Times (specify) _______

☐ None

BASE: If ED1>0

ED1a. How many of those times were related to injuries or conditions resulting from opioid addiction?

☐ Times (specify) _______

☐ None

9. Self-Help Groups (SH)

BASE: All clients not previously sent to END

SH1. Over the past 90 days, how many times did you attend a self-help group, like Alcoholics or Narcotics Anonymous?

1. ☐ Never

2. ☐ Less than once a week

3. ☐ Once a week

4. ☐ More than once a week

5. ☐ Almost every day of the week

10. Primary Care Services (PC)

BASE: All clients not previously sent to END

PC1. Over the past 90 days, how many times did you visit a primary care provider (e.g. family doctor, internists, gynecologists, physician assistant or a nurse practitioner)?

☐ Times (specify) _______

☐ None

BASE: If PC1>0

PC1a. How many of those times were related to injuries or conditions resulting from opioid addiction?

☐ Times (specify) _______

☐ None

11. Medication and Counseling Use (HM)

HM1. Did you receive methadone treatment for opioid addiction at any time in the past 90 days? (Consider treatment received at ANY facility.)

1. ☐ Yes

2. ☐ No

HM2. Did you receive oral buprenorphine (e.g. Suboxone or generic) treatment for opioid addiction at any time in the past 90 days? (Consider treatment received at ANY facility.)

1. ☐ Yes

2. ☐ No

HM3. Did you receive implantable or injectable buprenorphine (e.g. Probuphine or generic) treatment for opioid addiction at any time in the past 90 days? (Consider treatment received at ANY facility.)

1. ☐ Yes

2. ☐ No

HM4. Did you receive oral naltrexone (e.g. Revia) treatment for opioid addiction at any time in the past 90 days? (Consider treatment received at ANY facility.)

1. ☐ Yes

2. ☐ No

HM5. Did you receive injectable naltrexone (e.g. Vivitrol) treatment for opioid addiction at any time in the past 90 days? (Consider treatment received at ANY facility.)

1. ☐ Yes

2. ☐ No

HM6. Did you receive counseling (either individual or group) treatment for opioid addiction at any time in the past 90 days? (Consider treatment received at ANY facility.)

1. ☐ Yes

2. ☐ No

12. Substance Abuse History (SU)

These next questions are about:

street drugs you used illicitly

prescription drugs that you used non-medically

alcohol and tobacco use

Non-medically means

Used your prescribed drugs in a way other than directed by a doctor

Used prescription drugs that were not prescribed for you personally

Used any prescription drug to get high or buzzed

Used any prescription drug to self-treat a medical condition

BASE: All clients not previously sent to END

Programmer note: Do NOT randomly order any lists in this section. Checked = 1, not checked=0.

SU1a-o. Over the past 90 days, how often did you use:

a) Prescription opioids used non-medically (e.g., OxyContin, Percocet, Dilaudid, Opana, Vicodin, Duragesic, Ultram, Morphine, Tramadol)

1. ☐ Never

2. ☐ Less than once a week

3. ☐ Once a week

4. ☐ More than once a week

5. ☐ Almost every day of the week

b) Prescription opioid treatment medications used non-medically (e.g., Methadone, Suboxone)

c) Prescription stimulants used non-medically (e.g., Ritalin, Adderall)

d) Prescription sedatives used non-medically (e.g., Xanax, Klonopin, Ativan)

e) Heroin

f) Illicitly-made fentanyl (not the prescription Duragesic patches)

g) Neuropathics used non-medically (e.g., gabapentin, pregabalin)

h) Marijuana/ Cannabis

i) Cocaine/Crack (e.g., powder, rock, or in any form/combination)

j) Methamphetamine/crank

k) Krokodil

l) Ecstasy, PCPs, or other synthetics

m) Inhalants

n) Alcohol

o) Tobacco

Programmer Note: For fill-in, use the following short names:

a) Prescription opioids

b) Methadone/Suboxone

c) Prescription stimulants

d) Prescription sedatives

e) Heroin

f) Fentanyl

g) Gabapentin

h) Marijuana/Cannabis

i) Cocaine/Crack

j) Methamphetamine/crank

k) Krokodil

l) Ecstasy, PCPs, or other synthetics

m) Inhalents

n) Alcohol

o) Tobacco

BASE: SU1 a) or b) > Never

SU3. Over the past 90 days, how many days did you use prescription opioids non-medically?

☐ Days (specify 1-90) _______

☐ None

BASE: SU3 > None

SU4. Over the past 30 days, how many days did you use prescription opioids non-medically?

☐ Days (specify 1-30) _______

☐ None

BASE: SU1 e) > Never

SU5. Over the past 90 days, how many days did you use heroin?

☐ Days (specify 1-90) _______

☐ None

BASE: SU5 > None

SU6. Over the past 30 days, how many days did you use heroin?

☐ Days (specify 1-30) _______

☐ None

BASE: SU1 f) > Never.

SU7. Over the past 90 days, how many days did you use illicitly-made fentanyl?

☐ Days (specify 1-90) _______

☐ None

BASE: SU7 > None

SU8. Over the past 30 days, how many days did you use illicitly-made fentanyl?

☐ Days (specify 1-30) _______

☐ None

13. Drug Overdoses (DO)

BASE: All clients not previously sent to END

DO1. Over the past 90 days, how many times did you have a drug overdose?

☐ Times (specify 1-90) _______

☐ None

Base: DO1>0

DO2. Over the past 90 days, how many times did you overdose due to opioids?

☐ Times (specify 1-90) _______

☐ None

BASE: DO2>0

Programmer note: Do NOT randomly order list. Checked=1, not checked=0

DO3. Thinking about your last overdose that involved opioids, were you administered naloxone?

1. ☐ Yes

2. ☐ No

BASE: DO3=Yes

DO4. Who provided the naloxone?

1. ☐ First responder (Emergency Medical Service /police/fire fighter)

2. ☐ A person with me had naloxone and gave it to me

3. ☐ Other professional (i.e. counselor, CBO staff, etc.)

4. ☐ I had naloxone and someone gave it to me

5. ☐ Other way (specify): _________________________

14. Pregnancy (PO)

BASE: If female

PO1. Are you currently pregnant?

1. ☐ Yes

2. ☐ No

3. ☐ I don’t know/ would rather not say

15. How You are Feeling Physically (BF)

Analyst note: This is BRFSS Quality of Life items

BASE: All not previously sent to END.

BF1. Would you say that in general your health is:

1. ☐ Excellent

2. ☐ Very good

3. ☐ Good

4. ☐ Fair

5. ☐ Poor

BASE: All not previously sent to END.

BF2. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? (Check None if zero days.)

☐ Days (specify 1-30) _______

☐ None

BASE: All not previously sent to END.

BF3. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? (Check None if zero days.)

☐ Days (specify 1-30) _______

☐ None

16. How You are Feeling Emotionally (PQ)

Analyst note: This is Depression Module - PHQ-8 (PQ)

BASE: All not previously sent to END

Programmer note: Randomly order list.

PQ1a-h. Over the past 2 weeks, how often have you been bothered by any of the following problems?

a) Little interest or pleasure in doing things

1. ☐ Not at all

2. ☐ Several days

3. ☐ More than half the days

4. ☐ Nearly every day

b) Feeling down, depressed, or hopeless

c) Trouble falling or staying asleep, or sleeping too much

d) Feeling tired or having little energy

e) Poor appetite or overeating

f) Feeling bad about yourself — or that you are a failure or have let yourself or your family down

g) Trouble concentrating on things, such as reading the newspaper or watching television

h) 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

17. Date of Birth

BASE: All clients not previously sent to END.

D1. Your date of birth (DOB)

MM/DD/YY

Programmer note: D1 is required to cross verify client identity. If refused, go to END/ENCOURAGE. The END/ENCOUAGE module encourages the R to please provide the information so they can complete the questionnaire.

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