WSR Form 2
This form has 18 short sections consisting of 2 or more multiple choice questions to gauge your symptoms and history. Please fill this in at least 24hrs before your assessment appointment.
Category: Uncategorized
What are your preferred pronouns?
Do you suffer from any of the following? (select as appropriate)
Note: These questions are required to ensure your safety in the event you are prescribed medication by our service.
Category: Attention
This section will ask you questions to understand how you view your ability to concentrate. The questions relate to how you behave in
your day to day life.
Do you struggle with attention to detail whilst completing tasks?
For example: Do you make careless mistakes?
Do you struggle with remaining focused?
For example: If you are reading a book, do you easily forget what you are reading because you have lost focus on what you are reading?
Do you struggle listening to what you are hearing?
For example: If someone is talking to you, do you easily lose concentration on what they are saying?
Do you struggle to finish tasks?
For example: If you are given a task at work, do you struggle to complete it?
Do you struggle with being organised?
For example: Do you struggle with organising your time or diary which may result in you missing appointments or deadlines?
Do you avoid avoid or dislikes activities requiring effort?
For example: If you were asked to do a task which would require several hours of work with lots of complexity.
Do you often lose or misplace items?
For example: Do you often lose your keys, wallet, or other items?
Do you easily feel distracted in day to day activities?
Do you feel like you’re forgetting to do things a lot?
For example: Paying bills, attending appointments or completing household tasks.
Category: Hyperactive and Impulsivity
This section focuses on whether you feel you are over active (in other words struggle to remain still and be quiet) and you react without
being able to control yourself.
Do you feel like you often fidget or squirm?
For example: Often rubbing your hands together / tapping your feet.
Do you struggle to stay seated at times when you are expected to do so?
For example: In a work meeting, whilst eating a meal or at the cinema.
Do you feel restless and need to move around frequently when you’re sitting still?
Do you feel like you’re a loud person who struggles to be quiet?
Do you feel compelled to always be active and physically on the go?
For example: You struggle to sit still and instead always want to be doing a physical activity.
Do you think you talk more than the people around you?
Do you blurt out comments without fully thinking them through?
Do you dislike waiting?
For example: Do you feel annoyed / stressed when you are in a traffic jam or waiting in line?
Do you interrupt others when they are speaking / when they’re occupied with something?
Category: Oppositional
This section is designed to understand how you respond to others in day to day life.
Do you feel you often lose your temper?
Do you feel you get easily annoyed?
Do you often feel angry or resentful at others?
Do you feel you often argue with others?
Do you feel you struggle when being asked to do something by someone else (another name for this is being 'defiant')?
Do you deliberately annoy other people?
Do you often blame other people when things go wrong in your life? (Even if it is not their fault)
Do you often feel spiteful (want to hurt others, physically or emotionally)?
Category: Development and Learning
This section is designed to explore how you developed during your childhood
Did you struggle with wetting the bed or your clothes after the age of 5?
After the age of soil, did you soil the bed or your clothes?
Did you struggle to keep up with children of your age in regards your ability to read?
Did you struggle to keep up with children of your age in regards your ability to spell words?
Did you struggle to keep up with children of your age in regards your ability to do maths sums?
Did you struggle to keep up with children of your age in regards your ability to write?
Category: Autism Spectrum
This section is designed to identify if you exhibit any signs of 'autism'.
Do you struggle to hold a conversation with others?
For example: Do you struggle to keep a conversation going and often feel stuck for how to respond to what people are saying to you?
Do you feel you struggle to maintain eye contact with people when they are interacting with you?
Do you feel you struggle to adjust your speech whilst having a conversation with others?
For example: Do you use words which do not really reflect what you were thinking or does the tone of your voice not represent your true feelings.
Do you feel that you become obsessed or fixed on certain ideas of interests and struggle to move past them?
For example: Do you become 'obsessed' with a particular hobby that it can start to dominate your life leaving not much time for other pursuits.
Do you feel you perform repetitive movements over and over again? For example, flapping your hands.
Do you feel you struggle to have 'chit chat' with others?
Category: Motor Disorder
This section is designed to understand your physical behaviour (how you move your body)
Do you make repetitive noises?
For example: Sniffing / throat clearing.
Do you perform repetitive movements?
For example: Blinking, smacking lips together / shrugging.
Would you say you are generally clumsy?
Category: Psychosis
This section is designed to explore if you are experiencing any unusual thoughts or feelings.
Do you hear voices which are not really there?
Do you see things which are not really there?
Do your thoughts feel like they are uncontrollably jumping between different ideas which are not often connected to one another?
Do you feel paranoid?
(this is a feeling that people are against you or out to get you)
Category: Depression
This section is designed to understand your mood and how you feel about yourself
Do you feel you have been sad, low in mood or depressed?
Do you feel you have a lack of interest or pleasure in doing things that you normally enjoy doing?
Do you feel you have no interest in eating or you are overeating to make yourself feel better?
Do you feel your mood or thoughts affect your sleeping? (This could mean you are either over or under sleeping)
Do you feel agitated?
Do you feel you are slow or sluggish in your thoughts?
Do you feel worthless?
Do you feel tired or lacking in energy?
Do you feel hopeless or pessimistic?
Do you feel you want to withdraw from people around you or your normal interests?
Do you feel that you have trouble concentrating more than before?
Category: Mood Regulation
This section is designed to explore how much control you have over your feelings.
Do you experience periods of intense excitement?
Do you experience periods of inflated ego or grandiose ideas?
Forexample, thinking you are the most important person or much more talented than other people? A feeling of no one can compare to how good you are.
Do you have periods of feeling extremely energetic?
Do you experience periods of a reduced need for sleep?
Do you experience periods of racing thoughts or speech?
Do you experience episodes of feeling irritable which is not normally part of your character?
Do you experience episodes of rage, angry outbursts, and episodes of hostility?
Category: Suicidal and self harm thoughts
Do you experience any suicidal thoughts?
If you have experienced suicidal thoughts, when did these occur?
Have you ever attempted suicide?
Category: Anxiety
This section is designed to understand if you feel stressed, worried or anxious.
Do you experience intense fears? For example, do you feel intense fears regarding such things as heights, crowds, spiders or anything else.
Do you experience fears of social situations or performing in public?
Do you experience panic attacks?
Do you fear leaving the house?
Do you feel worried or anxious?
Do you feel you can't relax?
Do you experience obsessive thoughts (e.g. germs, perfectionism)
Do you experience compulsive rituals (e.g. turning lights on and off or hand washing multiple times)
Do you perform behaviours such as: hair pulling, nail biting or skin picking?
Do you experience a preoccupation with worries about your physical health?
Do you suffer from chronic (long standing) pain?
Category: Stress Related Disorders
This section is designed to understand what aspects of your life may cause anxiety or affect your mental health.
Have you experienced any physical abuse in your life?
Have you experienced any sexual abuse?
Have you experienced Neglect?
Have you experienced any other emotional or physical trauma?
Category: PTSD
This section is to explore any evidence of post traumatic stress disorder.
Do you experience any recurring flashbacks or nightmares?
Do you find yourself avoiding situations which make you feel uncomfortable?
Do you experience intrusive thoughts of traumatic events (thoughts which you can not stop appearing in your mind).
Category: Sleep
This section is to explore how well you are sleeping and resting.
Do you experience trouble falling asleep or staying asleep?
Do you experience excessive daytime sleepiness?
Do you experience episodes of snoring or has someone told you that you hold your breath whilst sleeping?
Category: Eating
This section is to explore your eating habits.
Do you experience feelings of unhappiness in regards how your body looks?
Do you experience feelings of being underweight?
Do you ever binge eat?
Do you perceive yourself to be overweight?
Do you ever refuse to eat or eat only very little quantities?
Category: Conduct
Are you ever verbal aggressive to others?
Are you often physically aggressive to others?
Have you ever used a weapon against people (stones, sticks etc.)?
Have you ever been cruel to animals?
Are you physically cruel to people?
Have you ever stolen items or shop lifted?
Have you ever deliberately set inappropriate fires?
Have you ever deliberately destroyed property (your own, or belong to others)?
Do you often lie?
If you have done something others consider wrong, do you feel remorseful or guilty?
Do you struggle to empathise (be aware of and understand) how others are feeling?
Category: Substance Use
Misuse of prescription drugs
Do you drink over 14 alcoholic drinks per week or/and more than 4 alcoholic drinks in a row?
Smoking or tobacco use
Marijuana
Other street drugs
Excessive over the counter medications
Excessive caffeine (colas, coffee, tea, pills)
Category: Addictions
Gambling
Excessive internet, gaming or screen time
Other addiction
Category: Personality
Would you describe yourself as Self-destructive?
Do you often engage in stormy and conflicted relationships? N
Do you engage in Self-injurious behaviour (e.g. cutting yourself)
Do you experience low self-esteem?
Would you describe yourself as manipulative?
Would you describe yourself as behaving in a self cantered manner?
Would you describe yourself as behaving arrogantly?
Would you describe yourself as being suspicious of others?
Do you often lie to others without feeling remorse or shame?
Do you often break the law or behave antisocially?
Would you describe yourself as a 'loner'? (distancing yourself from others and society)
Your score is
