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Do you have a long term medical condition? (e.g. cancer, diabetes, heart disease, stroke)
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If yes, please describe the nature of your condition
Your Own Reactions Now to the Grenfell Tower Fire
Please consider the following reactions which sometimes occur after the Grenfell Tower Fire. This questionnaire is concerned with your personal reactions to the traumatic event. Please indicate whether or not you have experienced any of the following AT LEAST TWICE IN THE PAST WEEK:
Upsetting thoughts or memories about the event that have come into your mind against your will
Yes, at least twice in the past week
No
Upsetting dreams about the event
Yes, at least twice in the past week
No
Acting or feeling as though the event were happening again
Yes, at least twice in the past week
No
Feeling upset by reminders of the event
Yes, at least twice in the past week
No
Bodily reactions (such as fast heartbeat, stomach churning, sweatiness, dizziness) when reminded of the event
Yes, at least twice in the past week
No
Difficulty falling or staying asleep
Yes, at least twice in the past week
No
Irritability or outbursts of anger
Yes, at least twice in the past week
No
Difficulty Concentrating
Yes, at least twice in the past week
No
Heightened awareness of potential dangers to yourself and others
Yes, at least twice in the past week
No
Being jumpy or being startled at something unexpected
Yes, at least twice in the past week
No
® C.R. Brewin et al., 2002
PHQ-4
Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious or on edge
Not at all
Several days
More than half the days
Nearly every day
Not being able to stop or control worrying
Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless
Not at all
Several days
More than half the days
Nearly every day
The PHQ scales were developed by Drs. Robert L. Spitzer, Janet B.W. Williams, and Kurt Kroenke and colleagues. The PHQ scales are free to use. For research information, contact Dr. Kroenke at kkroenke@regenstrief.org
Other Information
Ethnicity
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White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black backgrond
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Do you have any specific needs or disabilities - e.g. Mobility problems, need for interpreter? If yes, please describe
Please describe the problem you need help with
Have you ever received, or are currently receiving, treatment or support for these difficulties? If yes, please describe
Where did you hear about us?
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Word of Mouth
GP
Met NHS Staff in my community
NHS Staff using Virtual Reality in my community
Friend / Family
NHS Staff knocked on my door
NHS Staff called me on my phone
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