Questionnaire 3

HEALING SICK HOUSES - QUESTIONNAIRE THREE

This is the third questionnaire. If possible we would like you to complete this questionnaire on the day that you receive it, or as soon as possible thereafter. Your house has received our healing treatment. Please return the completed questionnaire to Dr Wass at Cardiff University in the SAE provided.

As before there are three types of question: the first requires you to tick in the box beside the appropriate answer (e.g. ), the second requires you to circle a number (e.g. ) and the third requires you to write the answer in your own words (e.g.........). Please answer questions 4 to 7 for the same person as in the previous questionnaire.

Case Number ............

1. Please indicate the date and time at which you completed this questionnaire.
Time am/pm ............ date............

2. Have you noticed any changes relating to your house and/or to how you feel about your house?

yes no

3. Please describe any changes that you have noticed ...........................................

.........................................................................................................................................

.........................................................................................................................................

.........................................................................................................................................

Please answer questions 4 to 7 for the same person as in the previous questionnaire.

4. How would you describe the general health or wellbeing of the chosen person over the last week?
Very good Good Fair Poor Very poor

5. Has the health of this person changed since your replies in Questionnaire One? yes no

6. Please describe any changes that you have noticed ...........................................

.........................................................................................................................................

7. For each of the conditions listed below, please circle the number that most closely describes the experience of the chosen person over the last week.

If you have not experienced the condition, please circle 0 and you need not complete the rest of the line.

		Not experienced	To a mild degree	To a moderate degree	To an intense degree	A little of the time	Some of the time	A good deal of the time	Most of the time	All of the time
A	Lack of interest and motivation	0	1	2	3	1	2	3	4	5
B	Suffer from repeated infections	0	1	2	3	1	2	3	4	5
C	Downhearted and low	0	1	2	3	1	2	3	4	5
D	Calm and peaceful	0	1	2	3	1	2	3	4	5
E	Full of life and vitality	0	1	2	3	1	2	3	4	5
F	Physically worn down	0	1	2	3	1	2	3	4	5
G	Mentally worn down	0	1	2	3	1	2	3	4	5
H	Lack of energy	0	1	2	3	1	2	3	4	5
I	Problems with neighbours	0	1	2	3	1	2	3	4	5
J	Worried about health	0	1	2	3	1	2	3	4	5
K	Worried about home	0	1	2	3	1	2	3	4	5
L	Happy and contented	0	1	2	3	1	2	3	4	5
M	Trouble sleeping	0	1	2	3	1	2	3	4	5
N	Bad dreams	0	1	2	3	1	2	3	4	5
O	Strange happenings at home	0	1	2	3	1	2	3	4	5
P	Problems at work	0	1	2	3	1	2	3	4	5
Q	Optimistic	0	1	2	3	1	2	3	4	5
R	Worried about money	0	1	2	3	1	2	3	4	5
5S	Unsettled at home	0	1	2	3	1	2	3	4	5
T	Anxious and tense	0	1	2	3	1	2	3	4	5
U	Generally troubled	0	1	2	3	1	2	3	4	5
V	Problems with electrical equipment	0	1	2	3	1	2	3	4	5
W	Domestic harmony	0	1	2	3	1	2	3	4	5
X	Bad atmosphere at home	0	1	2	3	1	2	3	4	5
Y	Difficult relationships	0	1	2	3	1	2	3	4	5
Z	Bad luck	0	1	2	3	1	2	3	4	5

8. Please add anything that you think would be of interest .......................................

.........................................................................................................................................

We are grateful for your help, thank you.