Veterans' Baseline

Private and Confidential when completed

Confidential Impact and Effectiveness Questionnaire

Section 1:

Over the last 6 weeks, how often have you:

Not at all
Odd days
More than half the days
Nearly every day
Not at all
Odd days
More than half the days
Nearly every day
Not at all
Odd days
More than half the days
Nearly every day
Not at all
Odd days
More than half the days
Nearly every day
Not at all
Odd days
More than half the days
Nearly every day
Not at all
Odd days
More than half the days
Nearly every day
Not at all
Odd days
More than half the days
Nearly every day

Section 2:

In the last 6 months:

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

If you responded 'Yes' to any of the above, how much of a problem did this cause you? EG being unable to work, losing close family links, money or legal troubles.

No problem
Minor Problem
Moderate Problem
Serious Problem

Declaration

If not signed, registration cannot be processed.

Yes
No
Yes
No
Yes
No

I understand by printing my name on the signature line provided, this counts as my signature

Please note that all data is treated with the strictest confidentiallity and will be held in accordance to the Data Protection Act.

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