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Questionnaire

To better understand your unique situation and assess the impact and effectiveness of my services, I kindly ask you to complete the following questionnaire.


By filling out the same questionnaire at the end of our sessions/program, we can track any changes and progress over time.

The questionnaire takes approximately 5–10 minutes to complete. Some questions may seem similar, but each one serves a distinct purpose—please answer them individually.

The best approach is to respond intuitively and avoid overthinking; simply select the option that feels most accurate.


Rest assured that all information will be handled with the utmost confidentiality and will not be shared with anyone.


Thank you for your time and participation!

Please answer the following questions:

1. How often do you feel tired? (PB)
1. Always
2. Often
3. Sometimes
4. Seldom
5. Never/almost never
2. Does your work frustrate you? (W)
To a very high degree
To a high degree
Somewhat
To a low degree
To a very low degree
3. How often are you emotionally exhausted? (PB)
1. Always
2. Often
3. Sometimes
4. Seldom
5. Never/almost never
4. Do you feel burnt out because of your work? (W)
To a very high degree
To a high degree
Somewhat
To a low degree
To a very low degree
5. How often do you think: ”I can’t take it anymore”? (PB)
1. Always
2. Often
3. Sometimes
4. Seldom
5. Never/almost never
6. How often are you physically exhausted? (PB)
1. Always
2. Often
3. Sometimes
4. Seldom
5. Never/almost never
7. How often do you feel worn out? (PB)
1. Always
2. Often
3. Sometimes
4. Seldom
5. Never/almost never
8. Do you have enough energy for family and friends during leisure time? (W)
1. Always
2. Often
3. Sometimes
4. Seldom
5. Never/almost never
9. Are you exhausted in the morning at the thought of another day at work? (W)
1. Always
2. Often
3. Sometimes
4. Seldom
5. Never/almost never
10. How often do you feel weak and susceptible to illness? (PB)
1. Always
2. Often
3. Sometimes
4. Seldom
5. Never/almost never
11. Do you feel worn out at the end of the working day? (W)
1. Always
2. Often
3. Sometimes
4. Seldom
5. Never/almost never
12. Do you feel that every working hour is tiring for you? (W)
1. Always
2. Often
3. Sometimes
4. Seldom
5. Never/almost never
13. Is your work emotionally exhausting? (W)
To a very high degree
To a high degree
Somewhat
To a low degree
To a very low degree

In the last week, how often have you:

14. Been upset because something that happened unexpectedly? (S)
0. Never
1. Almost never
2. Sometimes
3. Fairly often
4. Very often
15. Felt that you have been unable to control important things in your life? (S)
0. Never
1. Almost never
2. Sometimes
3. Fairly often
4. Very often
16. Felt nervous and ‘stressed’? (S)
0. Never
1. Almost never
2. Sometimes
3. Fairly often
4. Very often
17. Found that you could NOT cope with all the things you had to do? (S)
0. Never
1. Almost never
2. Sometimes
3. Fairly often
4. Very often
18. Been angered because of things that happened that were out of your control? (S)
0. Never
1. Almost never
2. Sometimes
3. Fairly often
4. Very often
19. Felt difficulties were piling up so high that you could not overcome them? (S)
0. Never
1. Almost never
2. Sometimes
3. Fairly often
4. Very often
20. Felt confident about your ability to handle your personal problems? (S)
0. Very often
1. Fairly often
2. Sometimes
3. Almost never
4. Never
21. Felt things were going your way? (S)
0. Very often
1. Fairly often
2. Sometimes
3. Almost never
4. Never
22. Been able to control irritations in your life? (S)
0. Very often
1. Fairly often
2. Sometimes
3. Almost never
4. Never
23. Felt that you were on top of things? (S)
0. Very often
1. Fairly often
2. Sometimes
3. Almost never
4. Never

Over the last week, how often have you been bothered by the following problems:

24. Feeling nervous, anxious or on edge? (A)
0. Not at all
1. Several days
2. Most of the days
3. Every day
25. Not being able to stop or control worrying? (A)
0. Not at all
1. Several days
2. Most of the days
3. Every day
26. Feeling down, depressed or hopeless? (D)
0. Not at all
1. Several days
2. Most of the days
3. Every day
27. Little interest or pleasure in doing things? (D)
0. Not at all
1. Several days
2. Most of the days
3. Every day
28. Repeated, disturbing memories, thoughts, or images of a stressful experience? (P)
1. Not at all
2. A little
3. Moderate
4. Quite a bit
5. Extremely
29. Feeling very upset when something reminded you of a stressful experience? (P)
1. Not at all
2. A little
3. Moderate
4. Quite a bit
5. Extremely
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Do you want to contact me?

Thank you for your message!

Phone number

+31(0)622044738

E-mail address

​

 

Tessavannes@kpnmail.nl

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