Questionnaire Oms Form PDF Details

Embarking on a journey to understand the dimensions of one's mental health and well-being can be both empowering and enlightening. The Questionnaire Oms form, designed for adults aged 18 to 64, serves as a beacon in this exploration, offering a structured way to reflect upon and articulate various aspects of one's life and mental state. Introduced on December 13, 2014, as part of the Outcomes Measurement System (OMS) (Version 3), this tool not only inquires about a person's living situation—spanning from private residences to institutional settings—but also delves into feelings of satisfaction with one’s current living arrangement, experiences of homelessness, and more. Furthermore, the questionnaire critically addresses the concept of recovery and functioning, asking individuals to rate their agreement with statements about confidence, hope, decision-making, goal-setting, and the impact of symptoms on their lives. Accompanying this introspective journey are questions regarding psychiatric symptoms, examining how difficulties in daily life, coping with problems, concentration, and social interactions have affected the individual over the past month. Each question is thoughtfully designed to provide insights into the respondent's mental health and recovery journey, making the Questionnaire Oms form a pivotal tool in the path toward wellness and self-understanding.

QuestionAnswer
Form NameQuestionnaire Oms Form
Form Length11 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 45 sec
Other namesadult questionnaire get, adult questionnaire pdf, adult questionnaire search, add questionnaire for adults

Form Preview Example

ADULT QUESTIONNAIRE (18-64 YEARS)

OUTCOMES MEASUREMENT SYSTEM (OMS)

[VERSION 3; DECEMBER 13, 2014]

Client Name: __________________________________________

(pre-populated in online system)

Interviewer Name: __________________________________________

(pre-populated in online system)

*Date of Current Interview: ____ / ____ / ________

MM DD YYYY

A companion OMS Interview Guide for this questionnaire is available at

www.maryland.valueoptions.com.

The symbol (Ψ) denotes a client opinion only question.

An asterisk (*) denotes a question that is mandatory for submission.

Underlined questions indicate that a definition is available for a term within the questionnaire. Click on the hyperlink that appears in order to access the definition.

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1

LIVING SITUATION

I’m going to ask you some questions today about different areas of your life, such as your living situation and daily activities.

*1. Where are you living now? (see OMS Interview Guide for more specific definitions)

OIndependent (Private Residence, Boarding House/Rooming House)

OCommunity (Residential Rehabilitation Program, Group Home/Therapeutic Group Home, Halfway House, Recovery Residence, School or Dormitory, Foster Home, Crisis Residence)

OInstitutional (Assisted Living, Skilled Nursing Facility, Residential Treatment Center for Children, Hospital, Jail/Correctional Facility/Detention Center)

OHomeless (Homeless or Emergency Shelter)

OOther (specify) _______________________________________________

(INTERVIEWER: Read all the answer options to the client)

2.In general, how satisfied are you with where you currently live? Ψ

O Not at all O A little bit O Somewhat O Quite a bit O Very much

3.Have you been homeless at all in the past six months? (see OMS Interview Guide for definition of “homeless”)

O No O Yes

(continued on next page)

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2

RECOVERY AND FUNCTIONING

Now I am going to read a series of statements. As I read each statement, please indicate how much you agree with it: Not at all, A little bit, Somewhat, Quite a bit, or Very much.

[CARD #1 with response options]

Please note that Questions 4-13 1 are

Not at

A little

Somewhat

Quite a

Very

all Ψ (Client Opinion Only)

all

bit

bit

much

 

4.

I am confident that I can make positive

 

 

 

 

 

 

changes in my life.

 

 

 

 

 

5.

I am hopeful about the future.

 

 

 

 

 

6.

I believe I make good choices in my life.

 

 

 

 

 

7.

I am able to set my own goals in life.

 

 

 

 

 

8.

I feel accepted as who I am.

 

 

 

 

 

9.

I do things that are meaningful to me.

 

 

 

 

 

10. I am able to take care of my needs.

 

 

 

 

 

11. I am able to handle things when they go

 

 

 

 

 

 

wrong.

 

 

 

 

 

12. I am able to do things that I want to do.

 

 

 

 

 

13. My symptoms bother me. (see OMS

 

 

 

 

 

Interview Guide for definition of “symptoms”)

 

 

 

 

 

1Items 4-8 are from the Maryland Assessment of Recovery Scale-Short Form; used with permission (Drapalski, et. al, 2012).

(INTERVIEWER: Read all the answer options to the client)

14.Overall, how satisfied are you with your recovery? Ψ (description of “recovery” in italics below)

O Not at all O A little bit O Somewhat O Quite a bit O Very much

[“Recovery from Mental Disorders and/or Substance Use Disorders is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”

(U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2011)]

12/13/14

3

PSYCHIATRIC SYMPTOMS

For the next several questions, please tell me your answer based on the past MONTH.

INTERVIEWER: (do not read aloud) For items 15-38, you must either show the designated Response Card, give the client a copy of the questionnaire to follow along, or read all of the response options for each question to the client.

(Questionnaire Items 15-38 comprise the BASIS-24; ©McLean Hospital. Used and modified with permission.)

During the PAST MONTH, how much difficulty did you have…

15.Managing your day-to-day life? Ψ [CARD #2 with response options]

O No difficulty O A little difficulty

O Moderate difficulty O Quite a bit of difficulty O Extreme difficulty

16.Coping with problems in your life? Ψ [CARD #2]

O No difficulty O A little difficulty

O Moderate difficulty O Quite a bit of difficulty O Extreme difficulty

17.Concentrating? Ψ [CARD #2]

O No difficulty O A little difficulty

O Moderate difficulty O Quite a bit of difficulty O Extreme difficulty

During the PAST MONTH, how much of the time did you…

18.Get along with people in your family? Ψ [CARD #3 with response options]

O None of the time O A little of the time O Half of the time O Most of the time O All of the time

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4

19.Get along with people outside your family? Ψ [CARD #3]

O None of the time O A little of the time O Half of the time O Most of the time O All of the time

20.Get along well in social situations? Ψ [CARD #3]

O None of the time O A little of the time O Half of the time O Most of the time O All of the time

21.Feel close to another person? Ψ [CARD #3]

O None of the time O A little of the time O Half of the time O Most of the time O All of the time

22.Feel like you had someone to turn to if you needed help? Ψ [CARD #3]

O None of the time O A little of the time O Half of the time O Most of the time O All of the time

23.Feel confident in yourself? Ψ [CARD #3]

O None of the time O A little of the time O Half of the time O Most of the time O All of the time

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5

During the PAST MONTH, how much of the time did you…

24.Feel sad or depressed? Ψ [CARD #3]

O None of the time O A little of the time O Half of the time O Most of the time O All of the time

25.Think about ending your life? Ψ [CARD #3]

O None of the time O A little of the time O Half of the time O Most of the time O All of the time

26.Feel nervous? Ψ [CARD #3]

O None of the time O A little of the time O Half of the time O Most of the time O All of the time

During the PAST MONTH, how often did you…

27.Have thoughts racing through your head? Ψ [CARD #4 with response options]

O Never O Rarely

O Sometimes O Often

O Always

28.Think you had special powers? Ψ [CARD #4]

O Never O Rarely

O Sometimes O Often

O Always

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6

29.Hear voices or see things? Ψ [CARD #4]

O Never O Rarely

O Sometimes O Often

O Always

30.Think people were watching you? Ψ [CARD #4]

O Never O Rarely

O Sometimes O Often

O Always

31.Think people were against you? Ψ [CARD #4]

O Never O Rarely

O Sometimes O Often

O Always

During the PAST MONTH, how often did you…

32.Have mood swings? Ψ [CARD #4]

O Never O Rarely

O Sometimes O Often

O Always

33.Feel short tempered? Ψ [CARD #4]

O Never O Rarely

O Sometimes O Often

O Always

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7

34.Think about hurting yourself? Ψ [CARD #4]

O Never O Rarely

O Sometimes O Often

O Always

During the PAST MONTH, how often…

35.Did you have an urge to drink alcohol or take street drugs? Ψ [CARD #4]

O Never O Rarely

O Sometimes O Often

O Always

36.Did anyone talk to you about your drinking or drug use? Ψ [CARD #4]

O Never O Rarely

O Sometimes O Often

O Always

37.Did you try to hide your drinking or drug use? Ψ [CARD #4]

O Never O Rarely

O Sometimes O Often

O Always

38.Did you have problems from your drinking or drug use? Ψ [CARD #4]

O Never O Rarely

O Sometimes O Often

O Always

12/13/14

8

LEGAL SYSTEM INVOLVEMENT

*39. In the past six months have you been arrested?

ONo

OYes

*40. In the past six months have you been in either jail or prison?

ONo

OYes

EMPLOYMENT

Now let’s talk a little bit about your work situation.

*41. Are you currently employed? (see OMS Interview Guide for definition of “employment”)

ONo (continue to #42)

OYes (skip to #43)

*42. Have you been employed in the past six months? [mandatory only if Question 41 is “No”]

ONo (skip to #45)

OYes (continue to #43)

INTERVIEWER: (do not read aloud) If the person held more than one job in the past six months, please ask him or her to answer the following questions in terms of the most recent job.

43.How many hours a week (do/did) you usually work?

O 1-10 hours O 11-20 hours O 21-30 hours O 31-40 hours O 40+ hours

(INTERVIEWER: Read all the answer options to the client)

44.In general, how satisfied (are/were) you with this job? Ψ

O Not at all O A little bit O Somewhat O Quite a bit O Very much

12/13/14

9

SOMATIC HEALTH

*45. Do you smoke cigarettes?

ONo (skip to #47)

OYes (continue to #46)

46.How many cigarettes do you smoke per day? [one pack = 20 cigarettes]

ODo not smoke every day

O1-10

O11-20

O21-30

O30+

(INTERVIEWER: Read all the answer options to the client and check all that apply)

*47. In the past month did you use any of the following tobacco products?

OCigars (e.g., cigarillos, little cigars)?

OSmokeless tobacco (e.g., chewing tobacco, dip, snuff)?

OElectronic-cigarettes (e.g., e-cigarettes, vaporizer cigarettes, vapes)?

OPipes (e.g., hookah, water pipes)?

OOther tobacco product (e.g., bidis, kreteks, clove cigarettes)?

ONone

(INTERVIEWER: Read all the answer options to the client)

48.Would you say in general your health is: Ψ

O Excellent O Very good O Good

O Fair O Poor

49.How tall are you?

____ (feet) ______ (inches) [please write legibly]

50. How much do you currently weigh?

____________ pounds [whole numbers only; please write legibly]

ODon’t Know

ORefused

12/13/14

10

Clinician’s Notes (Optional)

12/13/14

11