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CORE 10 SCREENING MEASURE
CLINICAL OUTCOMES in ROUTINE EVALUATION
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Email
*
Your email
DATE FORM COMPLETED
*
MM
/
DD
/
YYYY
GENDER
*
Female
Male
Prefer not to say
Other:
AGE
Your answer
STAGE FORM COMPLETED
*
Referral (pre consultation)
During or post consultation
Review 1 (Session 4)
Review 2 (Session 8)
Review 3 (Session 12)
Review 4 (Session 16)
Other:
IMPORTANT - PLEASE READ
This form has 10 statements about how you have been feeling
OVER THE PAST WEEK
.
Please read each statement and think about how often you have felt that way last week.
Then select the item which is closest to this.
1.] Over the last week I have felt tense, anxious or nervous
*
(0) Not at all
(1) Only occasionally
(2) Sometimes
(3) Often
(4) Most or all of the time
2.] Over the last week I have felt I have someone to turn to for support when needed
*
(4) Not at all
(3) Only occasionally
(2) Sometimes
(1) ) Often
(0) Most or all of the time
3.] Over the last week I have felt able to cope when things go wrong
*
(4) Not at all
(3) Only occasionally
(2) Sometimes
(1) Often
(0) Most or all of the time
4.] Over the last week talking to people has felt too much for me
*
(0) Not at all
(1) Only occasionally
(2) Sometimes
(3) Often
(4) Most or all of the time
5.] Over the last week I have felt panic or terror
*
(0) Not at all
(1) Only occasionally
(2) Sometimes
(3) Often
(4) Most or all of the time
6.] Over the last week I have made plans to end my life
*
(0) Not at all
(1) Only occasionally
(2) Sometimes
(3) Often
(4) Most or all of the time
7.] Over the last week I have had difficulty getting to sleep or staying asleep
*
(0) Not at all
(1) Only occasionally
(2) Sometimes
(3) Often
(4) Most or all of the time
8.] Over the last week I have felt despairing or hopeless
*
(0) Not at all
(1) Only occasionally
(2) Sometimes
(3) Often
(4) Most or all of the time
9.] Over the last week I have felt unhappy
*
(0) Not at all
(1) Only occasionally
(2) Sometimes
(3) Often
(4) Most or all of the time
10.] Over the last week unwanted images or memories have been distressing me
*
(0) Not at all
(1) Only occasionally
(2) Sometimes
(3) Often
(4) Most or all of the time
PLEASE ADD UP ALL THE OPTIONS YOU HAVE SELECTED USING THE NUMBERS IN THE BRACKETS AND PUT YOUR TOTAL SCORE BELOW
*
Your answer
PLEASE SELECT THE APPROPRIATE DISTRESS CATEGORY ACCORDING TO YOUR ANSWER ABOVE
*
0-5 = Healthy
6-10 = Low level problems
11-14 = Mild psychological distress
15-19 = Moderate distress
20-24 = Moderately severe distress
25 and above = Severe psychological distress
Thank you for your time in completing this questionnaire.
© Adapted from CORE System Trust:
https://www.coresystemtrust.org.uk
A copy of your responses will be emailed to the address you provided.
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