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SELF-ASSESSMENT QUESTIONNAIRE

Please complete the self-assessment form before making an appointment.

Taola Functionality Inventory (TFI)

Copyright 2016 by Dr. Senathi Fisha, All Rights Reserved.

Confidentiality

This questionnaire and responses thereof are strictly confidential between the patient and Employees of Fisha Wellness Institute who have taken a confidentiality Oath.

Instructions

  1. Please read the statements carefully
  2. Choose by selecting on the highest item applicable to how you feel today including the past four weeks

1. Depressed Mood
 I feel good about myself
 I spend most of my time feeling depressed than happy
 My depression is so bad that I can't hide it
 I am so depressed that I can't think of anything else
 I am depressed and care less of what happens nex
2. Disturbed Sleep
 I have no sleep problem
 My sleep patterns have changed
 I can't fall asleep unless I have taken sleeping tablets
 I wake up in the middle of the night and can’t fall asleep until early hours
 I sleep too much that it disturbs me
3. Loss of Interest
  Things are as interesting as before
  My interest for people and activities has declined
  I am no longer interested in social participation
  I am withdrawn from people and spend most of the time alone
  I lost so much interest in many things that I feel empty
4. Suicidal Ideation
  I have no thoughts of death as an option
  I have ideas of killing myself but not strong enough to carry them out
  I feel life is not worthy of anything
  I am actively planning to commit suicide and only a matter of time
  I wouldn't hesitate to kill myself and others if provoked
5. Low self esteem
  I have confidence in myself
  I feel people don’t appreciate what I do
  I am not confident of myself
  There is nothing good I can do for myself and others
  I am worthless and don't deserve anything good
6. Psychotic Features
  I don't hear, see, feel or smell things that are not there
  I sometimes hear people talking to me that others don't hear
  I sometimes see people that are not seen by other people
  I have special supernatural powers than others do
7. Anxiety Feelings
  I don't feel anxious out of the ordinary
  I get easily scared or fearful
  Lately feel as if something terrible is going to happen
  I feel as if there are butterflies in my stomach
  I am terrified about what will happen
8. Moods
  I rarely experience mood swings
  My moods changes for no apparent reason between high, low or irritables
  I often have racing thoughts, feel restless and talk very fasts
  I have abnormally increased energys
  I have abilities that no one hass
9. Anger outburst or irritation
 I don't get easily angry or irritable
 I get easily irritated by simple things
 I have too much anger that I can't control it
 I feel my anger will put me in trouble
 I need help to control my anger
10. Tension and Muscle Pains
  I don't suffer from physical ailments or pains
  I rarely suffer from any pain
  I often suffer from headache, neck, backache, chest and shoulder pains
  I always suffer from neck, shoulder pains and headache
  My body and headache are so severe that I can’t stand them
11. Fatigue and Loss of energy
  I have as much energy as ever
  I don't have much energy lately
  My body is heavy and my energy levels are low
  I feel fatigued and exhausted
  I am so tired and fatigued I can't tolerate it
12. Concentration Stress
  I don't have concentration problems
  I have short concentration span
  I lose focus in many things I do
  I find it difficult to put my mind on anything
  My concentration is so severe that it affects my life
13. Sexual Difficulties
  I have no sexual problems
  I like sex but lately my drive is low
  My sexual performance has decreased
  My interest in sex has increased excessively
  I have serious sexual problems and need help
14. Memory Disturbances
  I haven't noticed any memory changes
  I think I have memory problems
  I lately forgets most of things and this disturbs me
  I have serious memory problems that I resorted to assistive devices
  I need help for my memory problems
15. Medical Background

Did you or do you suffer from any of the following conditions listed below:

NB: there is more than one answer please select whichever is applicable.
  Diabetes, High Blood Pressure
  Arthritis, Neurological problems
  Epilepsy, Stomach Ulcers
  Cancer, Liver problems
  High cholesterol
  Heart problems, Lung Problems, TB, Kidney problems, Asthma

Any other
16. Additional Health Information

Weight information
  I haven't noticed any changes in my weight
  I am overweight
  I am underweight
  I am loosing/gaining weight
  I need help to manage my weight
Surgery
  I have had no surgical operations
  I had surgical operations

Type

How many

Years
Allergies
  I have no allergies that I am aware of
  I have allergies

I am allergic to the following

Do you have any other health issues?
  Yes   No

If yes, please specify
Medication
Are you on any medication?
  Yes   No

If yes, for which condition
17. Regular Assessments and Testing
(There is more than one answer please select whichever is applicable)
My blood group is

I have recently tested for stress
  Yes   No

My HIV status
  Positive
  Negative
  Unknown

I go for medical check annually
  Yes   No
18. Traumatic Incidence
  I don't have any traumatic experience that I can remember
  I was traumatized in the past
  I had experienced trauma /still traumatised and need help
  I am so traumatized by my experiences that I can't cope any longer
19. Addictions
  I don't have addiction problems
  I am addicted to drugs and substances
  I am addicted to alcohol
  I am addicted to cigarette smoking
  I am addicted to hard core drugs
  I am addicted to gambling
  I am addicted to sex
  I am addicted to social media
  I am addicted to internet
  I am addicted to buying clothes
  I am addicted to loan sharks
  I am addicted to pornography
20. Financial Stress
  I am financially balanced
  My finances are in shambles and I am overindebted
  I am locked up in long term financial debts
  I am unable to cater for my daily living expenses
  I need financial advice/ counselling
21. Occupational Stress
  I have no work related problems
  I am no more productive in my work
  I am dissatisfied with my work environment
  I am no longer interested in my job
22. Social Stress
  I have no social stress
  I have minor relationship problems
  I have serious relationship problems
  My social life is falling apart and something needs to be done restore it
23. Coping Skills
  My coping skills are adequate
  I have less coping skills to deal with my problems
  I have failed more than average to cope with my problems
  I think my world is falling apart around me
  I am totally unable to deal with my problems/situation
24. Used Coping strategies
I deal with my problems or challenges by doing the following