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Eagle's Eye Workshop Surveys
(Psychometric Self-evaluation Questionnaires)

The Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI)

 

THIS QUESTIONNAIRE SHOULD BE FILLED OUT AND SUBMITTED BOTH BEFORE AND AGAIN AFTER YOUR WORKSHOP EXPERIENCE. 

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It is preferred that you fill this out online and use the "Submit" button at the bottom to send the completed form to us automatically. However, if you choose to print out a hardcopy and mail it to us via postal mail that is acceptable also. Our address is:

Postal mail:

Best Medicine, Inc.

DBA Groking Wholeness

8022 Mays Avenue

Riverview, FL 33578

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Email:

eagleseye@grokingwholeness.info

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Questions or Concerns:

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Please call us at: 762-218-2663 (during normal business hours)

The Beck questionnaires should be filled out separately both before and after your workshop experience to assess whether you observed or encountered any psychological or physiological changes that you may have experienced as a result of the workshop. You may want to fill this form out at various intervals after your workshop experience as you may find that your answers may change as you integrate your workshop experience into your daily life.

Beck Depression Inventory (BDI)

and

Beck Anxiety Inventory (BAI)

PLEASE COMPLETE BOTH PARTS OF THIS QUESTIONNAIRE IMMEDIATELY BEFORE AND AFTER YOUR WORKSHOP EXPERIENCE

Start date of the workshop you attended
Month
Day
Year
Please indicate whether this is being completed "Before" or "After" the Workshop experience (Single choice)
This self-evaluation is being completed before the workshop experience
This self-evaluation is being completed after the workshop experience

Both parts of this survey is self scoring. The scoring scale is at the end of each part of the questionaire.

Part I - Beck Depression Inventory (BDI)

Question I.1 - (Single choice)
0 - I do not feel sad
1 - I feel sad
2 - I am sad all the time and I can't snap out of it
3 - I am so sad and unhappy that I can't stand it
Question I.2 - (Single choice)
0 - I am not particularly discouraged about the future
1 - I feel discouraged about the future
2 - I feel I have nothing to look forward to.
3 -I feel the future is hopeless and that things cannot improve.
Question I.3 - (Single choice)
0 - I do not feel like a failure.
1 - I feel I have failed more than the average person.
2 - As I look back on my life, all I can see is a lot of failures.
3 -I feel I am a complete failure as a person.
Question I.4 - (Single choice)
0 - I get as much satisfaction out of things as I used to.
1 - I don't enjoy things the way I used to.
2 - I don't get real satisfaction out of anything anymore.
3 -I am dissatisfied or bored with everything.
Question I.5 - (Single choice)
0 - I don't feel particularly guilty
1 - I feel guilty a good part of the time.
2 - I feel quite guilty most of the time.
3 -I feel guilty all of the time.
Question I.6 - (Single choice)
0 - I don't feel I am being punished.
1 -I feel I may be punished.
2 - I expect to be punished.
3 -I feel I am being punished.
Question I.7 - (Single choice)
0 - I don't feel disappointed in myself.
1 -I am disappointed in myself.
2 - I am disgusted with myself.
3 -I hate myself.
Question I.8 - (Single choice)
0 - I don't feel I am any worse than anybody else
1 -I am critical of myself for my weaknesses or mistakes.
2 - I blame myself all the time for my faults.
3 - I blame myself for everything bad that happens.
Question I.9 - (Single choice)
0 - I don't have any thoughts of killing myself.
1 - I have thoughts of killing myself, but I would not carry them out.
2 - I would like to kill myself.
3 - I would kill myself if I had the chance.
Question I.10 - (Single choice)
0 - I don't cry any more than usual.
1 - I cry more now than I used to.
2 - I cry all the time now.
3 - I used to be able to cry, but now I can't cry even though I want to.
Question I.11 - (Single choice)
0 - I am no more irritated by things than I ever was
1 - I am slightly more irritated now than usual.
2 - I am quite annoyed or irritated a good deal of the time.
3 - I feel irritated all the time.
Question I.12- (Single choice)
0 - I have not lost interest in other people.
1 - I am less interested in other people than I used to be.
2 - I have lost most of my interest in other people.
3 - I have lost all of my interest in other people.
Question I.13- (Single choice)
0 -I make decisions about as well as I ever could.
1 - I put off making decisions more than I used to.
2 - I have greater difficulty in making decisions more than I used to.
3 -I can't make decisions at all anymore
Question I.14- (Single choice)
0 - I don't feel that I look any worse than I used to.
1 - I am worried that I am looking old or unattractive.
2 - I feel there are permanent changes in my appearance that make me look unattractive
3 -I believe that I look ugly.
Question I.15 - (Single choice)
0 - I can work about as well as before.
1 - It takes an extra effort to get started at doing something.
2 - I have to push myself very hard to do anything.
3 - I can't do any work at all.
Question I.16 - (Single choice)
0 - I can sleep as well as usual.
1 - I don't sleep as well as I used to.
2 - I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.
3 -I wake up several hours earlier than I used to and cannot get back to sleep.
Question I.17 - (Single choice)
0 - I don't get more tired than usual.
1 - I get tired more easily than I used to.
2 - I get tired from doing almost anything.
3 -I am too tired to do anything.
Question I.18 - (Single choice)
0 - My appetite is no worse than usual.
1 - My appetite is not as good as it used to be.
2 -My appetite is much worse now.
3 -I have no appetite at all anymore.
Question I.19 - (Single choice)
0 - I haven't lost much weight, if any, lately.
1 - I have lost more than five pounds.
2 - I have lost more than ten pounds.
3 - I have lost more than fifteen pounds.
Question I.20 - (Single choice)
0 - I am no more worried about my health than usual
1 - I am worried about physical problems like aches, pains, upset stomach, or constipation.
2 - I am very worried about physical problems and it's hard to think of much else.
3 - I am so worried about my physical problems that I cannot think of anything else.
Question I.21 - (Single choice)
0 -I have not noticed any recent change in my interest in sex.
1 - I am less interested in sex than I used to be.
2 - I have almost no interest in sex.
3 - I have lost interest in sex completely.

INTERPRETING PART I (THE BECK DEPRESSION INVENTORY)

Now that you have completed part I of the questionnaire, add up the score for each of the twenty-one questions by counting the number to the left of each question you marked. The highest possible total for the whole test would be sixty-three. This would mean you circled number three on all twenty-one questions. Since the lowest possible score for each question is zero, the lowest possible score for the test would be zero. This would mean you circles zero on each question. You can evaluate your depression according to the Table below.

Part I: Levels of Depression

0 - 10: These ups and downs are considered normal

11 - 16: Mild mood disturbance

17 - 20: Borderline clinical depression

21 - 30: Moderate depression

31 - 40: Severe depression

over 40: Extreme depression

Part II - Beck Anxiety Index (BAI)

Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month OR since your last infusion, if you have started the ketamine infusion therapy. Circle one numnber in the corresponding space in the row next to each symptom.

Question II.1 - (Single choice)
0 - I do not feel numbness or tingling
1 - I mildly feel numbness or tingling but it doesn’t bother me much
2 - I moderately feel numbness or tingling and it wasn’t pleasant
3 - I severely feel numbness or tingling and it bothered me a lot
Question II.2 - (Single choice)
0 - I do not experience feeling hot
1 - I mildly experience feeling hot but it doesn’t bother me much.
2 - I moderately experience feeling hot and it wasn’t pleasant
3 - I severely experience feeling hot and it bothered me a lot
Question II.3 - (Single choice)
0 - I do not feel wobbliness in legs
1 - I mildly experience wobbliness in legs but it doesn’t bother me much
2 - I moderately experience wobbliness in legs and it wasn’t pleasant at times
3 - I severely experience wobbliness in legs and it bothered me a lot
Question II.4- (Single choice)
0 - I am able to relax
1 - I am mildly unable to relax but it doesn’t bother me much
2 - I am moderately unable to relax and it wasn’t pleasant at times
3 - I am severely unable to relax and it bothered me a lot
Question II.5- (Single choice)
0 - I do not have a fear of the worst happening
1 - I mildly have a fear of the worst happening but it doesn’t bother me much
2 - I moderately have a fear of the worst and it is not pleasant at time
3 - I severely have a fear of the worst and it bothers me a lot
Question II.6- (Single choice)
0 - I do not feel dizziness or lightheadedness
1 - I mildly feel dizziness or lightheadedness but it doesn’t bother me much
2 - I moderately feel dizziness or lightheadedness and it doesn’t feel pleasant at times
3 - I severely feel dizziness or lightheadedness and it bothers me a lot
Question II.7- (Single choice)
0 -I do not feel my heart pounding/racing
1 - I mildly feel my heart pounding/racing but it doesn’t bother me much
2 - I moderately feel my heart pounding/racing and it doesn’t feel pleasant at times
3 - I severely feel my heart pounding/racing and it bothers me a lot
Question II.8- (Single choice)
0 -I do not feel unsteady
1 - I mildly feel unsteady but it doesn’t bother me much
2 - I moderately unsteady and it doesn’t feel pleasant at times
3 -I severely feel unsteady and it bothers me a lot
Question II.9- (Single choice)
0 - I do not feel terrified or afraid
1 - I mildly feel unsteady but it doesn’t bother me much
2 - I moderately feel terrified or afraid and it doesn’t feel pleasant at times
3 - I severely feel terrified or afraid and it bothers me a lot
Question II.10- (Single choice)
0 - I do not feel nervous
1 - I mildly feel nervous but it doesn’t bother me much
2 - I moderately feel nervous and it doesn’t feel pleasant at times
3 -I severely feel nervous and it bothers me a lot
Question II.11- (Single choice)
0 - I do not have a feeling of choking
1 - I mildly have a feeling of choking but it doesn’t bother me much
2 - I moderately have a feeling of choking and it doesn’t feel pleasant at times
3 -I severely have a feeling of choking and it bothers me a lot
Question II.12- (Single choice)
0 - I do not experience hands trembling
1 - I mildly experience hands trembling but it doesn’t bother me much
2 - I moderately experience hands trembling and it doesn’t feel pleasant at times
3 - I severely experience hands trembling and it bothers me a lot
Question II.13- (Single choice)
0 - I do not feel shaky/unsteady
1 - I mildly feel shaky/unsteady but it doesn’t bother me much
2 - I moderately feel shaky/unsteady and it doesn’t feel pleasant at times
3 - I severely feel shaky/unsteady and it bothers me a lot
Question II.14- (Single choice)
0 - I do not have a fear of losing control
1 - I mildly have a fear of losing control but it doesn’t bother me much
2 - I moderately have a fear of losing control and it doesn’t feel pleasant at times
3 - I severely have a fear of losing control and it bothers me a lot
Question II.15- (Single choice)
0 - I do not have difficulty in breathing
1 - I mildly have difficulty in breathing but it doesn’t bother me much
2 - I moderately have difficulty in breathing and it doesn’t feel pleasant at times
3 - I severely have difficulty in breathing and it bothers me a lot
Question II.16- (Single choice)
0 - I do not have a fear of dying
1 - I mildly have a fear of dying but it doesn’t bother me much
2 - I moderately have a fear of dying and it doesn’t feel pleasant at times
3 - I severely have a fear of dying and it bothers me a lot
Question II.17- (Single choice)
0 - I do not feel scared
1 - I mildly feel scared but it doesn’t bother me much
2 - I moderately feel scared and it doesn’t feel pleasant at times
3 - I severely feel scared and it bothers me a lot
Question II.18- (Single choice)
0 - I do not experience indigestion
1 - I mildly experience indigestion but it doesn’t bother me much
2 - I moderately experience indigestion and it doesn’t feel pleasant at times
3 - I severely experience indigestion and it bothers me a lot
Question II.19- (Single choice)
0 - I do not feel faint/lightheaded
1 - I mildly feel faint/lightheaded but it doesn’t bother me much
2 - I moderately feel faint/lightheaded and it doesn’t feel pleasant at times
3 - I severely feel faint/lightheaded and it bothers me a lot
Question II.20 - (Single choice)
0 - I do not have face flushed
1 - I mildly have face flushed but it doesn’t bother me much
2 - I moderately have face flushed and it doesn’t feel pleasant at times
3 -I severely have face flushed and it bothers me a lot
Question II.21 - (Single choice)
0 -I do not have hot/cold sweats
1 - I mildly have hot/cold sweats but it doesn’t bother me much
2 - I moderately hot/cold sweats and it doesn’t feel pleasant at times
3 - I severely have hot/cold sweats and it bothers me a lot

INTERPRETING PART II (THE BECK ANXIETY INVENTORY)

Now that you have completed part II of the questionnaire, add up the score for each of the twenty-one questions (II.1 - II.21) by counting the number to the left of each question you marked. The highest possible total for the whole test would be sixty-three. This would mean you circled number three on all twenty-one questions. Since the lowest possible score for each question is zero, the lowest possible score for the test would be zero. This would mean you circles zero on each question. You can evaluate your depression according to the Table below.

Score of 0 - 21 = low anxiety

Score of 22 - 35 = moderate anxiety

score of 36 and above = potentially concerning levels of anxiety

This completes parts I and parts II of this questionnaire

PLEASE DO NOT CLICK ON THE "SUBMIT" BUTTON UNTIL YOU HAVE COMPLETED AND SCORED BOTH PARTS I AND II OF THIS QUESTIONNAIRE

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