Seasonal Affective Disorder Questionnaire

Part One November 2009

Please fill in the form below! Thank you for your help.

Full name:

Date of Birth:

Address and postcode:

E-mail:

Phone number (landline, please!):

Today's date:

How is your health at the moment? Please score with 0 being as good as it could be and 6 as bad as it could be

As good as it could be 0 1 2 3 4 5 6 As bad as it could be

Are you (please choose one):

Trying to conceive Pregnant Breastfeeding None

Are you taking any medication from your doctor?

Yes No

If YES, please list here what the medication is and what it is for, even if you think it is irrelevent to SAD.

Have you been medically diagnosed with SAD?

Yes No

Are you taking any medication from your doctor specifically for SAD?

Yes No

If YES, what? Please detail below.

Are you being treated by a homeopath or other complementary practitioner at the moment whether for SAD or not?

Yes No

If YES, what treatment are you receiving? Please detail below.

Are you taking any supplements for SAD such as vitamin D, St John's Wort etc?

Yes No

If YES, what are you taking? Please detail below.

Are you taking flower essences or homeopathic remedies or similar for SAD?

Yes No

If YES, what are you taking? Please detail below.

Are you using a light therapy in the form of a lightbox or sunrise (Lumie type) lamp?

Yes No

If YES, what are you using and how? Please detail below.

Are you using any other support measures for SAD?

Yes No

If YES, what are you using and how? Please detail below.

For how many years have you had SAD symptoms? years.

Please list your symptoms of SAD:

Choose one or two (physical or mental)symptoms that bother you the most writing them on the lines and consider how bad that symptom is now for you with 0 being as good as it could be and 6 being as bad as it could be.

Symptom 1:

As good as it could be 0 1 2 3 4 5 6 As bad as it could be

Symptom 2:

As good as it could be 0 1 2 3 4 5 6 As bad as it could be

Please list any activities (social, mental or physical) that are restricted by SAD:

Choose one or two activities (social, mental or physical) that are important to you and are prevented or restricted by SAD. Score how bad it is now with 0 being as good as it could be and 6 being as bad as it could be.

Activity 1:

As good as it could be 0 1 2 3 4 5 6 As bad as it could be

Activity 2:

As good as it could be 0 1 2 3 4 5 6 As bad as it could be

Thank you for completing this questionnaire for me, all information will be treated with the utmost confidentiality and used to benefit SAD sufferers. Your remedy will be mailed out to you as soon as possible and you will receive another questionnaire in January 2010 and a final questionnaire at the end of February 2010. If you have any questions please do not hesitate to contact me on research@fionadilston.co.uk or you can phone me on 0845 4639429. With many thanks Fiona Dilston.