Questionnaire on mood


  • We need your help for a study on mood.
  • The aim of this study is to compare three questionnaires assessing mood.
  • Please answer to ALL questions, even if some questions are repeated.
  • After answering, you will get a personalized report, with a rating of your mood and a comparison of your rating with reference scores.

Please answer the following questions based on how you have felt or what you have noticed over the last 24 hours. Answer based on how you have felt in general during this time:
1- Food is not particularly appealing to me
2- I am getting restful sleep
3- I have been tense or anxious
4- My level of concentration is excellent
5- I awaken from sleep frequently during the night
6- I have felt impatient
7- I have felt upbeat and optimistic
8- I have found myself worrying about my problems
9- I have had frequent urges to smoke
10- I have felt calm lately
11- I have been bothered by the desire to smoke a cigarette
12- I have felt sad or depressed
13- I have been irritable, easily angered
14- I want to nibble on snacks or sweets
15- I have been bothered by negative moods such as anger, frustration, and irritability
16- I have been eating a lot
17- I am satisfied with my sleep
18- I have felt frustrated
19- I have felt hopeless or discouraged
20- I have thought about smoking a lot
21- I have felt hungry
22- I feel that I am getting enough sleep
23- It is hard to pay attention to things
24- I have felt happy and content
25- My sleep has been troubled
26- I have trouble getting cigarettes off my mind
27- It has been difficult to think clearly
28- I think about food a lot
Comments on the 28 questions above:
(please specify question number)

The following statements describe how you feel today.
Please rate yourself for today:
Depressed mood (sad)
Insomnia (sleep problems, awakening at night)
Irritable, frustrated, angry
Anxious (nervous)
Difficulty concentrating
Restless (impatient)
Increased appetite, weight gain (hungry)
Desire or craving to smoke
Comments on the 8 questions above:

The following statements describe how you feel today.
Please indicate if you agree with each of these statements.

23a I feel depressed
66b I wake up often during the night
28c I have no motivation
63a I find it difficult to think clearly
39a I feel anxious
5e The only thing I can think about is smoking a cigarette
75b My appetite has increased
38d I feel worried
52 I am irritable
83a I would like to hold a cigarette between my fingers
28a My morale is low
55d I have NO patience
58b I find it hard to concentrate
77a I am eating more than usual
48c I get angry easily
11a I have an irresistible urge to smoke
45 I feel nervous
45b I feel restless
80d I have put on weight recently
10d I miss cigarettes terribly
63Cg I find it hard to focus on the task at hand
65c I have difficulty sleeping
10c I miss smoking terribly
23d I feel down
11c I feel an irresistible need to smoke
64e I have trouble falling asleep at night
Comments on the questions above :
(please specify question number)

Here are some questions about yourself:
Are you ?
When were you born? I was born in
In which country do you live?
Which is your mother tongue?
Other mother tongue, please specify:
Did you ever smoke 100 cigarettes in your lifetime?  
Did you smoke tobacco (even one puff of cigarette, cigar, pipe, etc) in the past 7 days?
Did you smoke tobacco (even one puff of cigarette, cigar, pipe, etc) in the past 4 weeks?
Do you currently smoke tobacco? a= Yes, I smoke tobacco every day
b= Yes, I smoke tobacco occasionally (not every day)
c= No, I am an EX-smoker
d= No, I was never a smoker
Currently, which type of tobacco do you use mainly? Currently, I use mainly:
Do you currently use a nicotine replacement product (nicotine patch, gum, inhaler, tablet, or nicotine nasal spray)?
Do you currently use the smoking cessation drug called "bupropion" or "Zyban"?
Is it likely that, in two months from now, you will be an EX-smoker?
In order to assess the stability of answers to this questionnaire, we would like to contact you in 2 weeks from now, to ask you the same questions again. If you agree, please indicate your first name and e-mail address: First name:

E-mail:

Questions for SMOKERS:
=> EX-smokers, please click here.
=> NEVER-smokers, please click here.
Please rate your addiction to cigarettes on a scale of 0 to 100:

- I am NOT addicted to cigarettes at all = 0
- I am extremely addicted to cigarettes = 100

Addiction
On average, how many cigarettes do you smoke per day? Cig./day
Usually, how soon after waking up do you smoke your first cigarette? Minutes
For you, quitting smoking for good would be...
Which of the following statements describes the best your current situation? 1 = I have NO intention to quit smoking in the next 6 months.
2 = I seriously consider quitting smoking in the next 6 months.
3 = I have decided to quit smoking in the next 30 days.

In the past 12 months, did you make an attempt to quit smoking?
Since you started to smoke regularly, how long lasted your longest period of smoking abstinence (= longest period WITHOUT smoking)? I spent a maximum of in a row without smoking.
If you started to smoke again, after an attempt to quit smoking:
When did you relapse to smoking? After trying to quit, I relapsed to smoking on:
Day:
Month:
Year:
On the day when you relapsed to smoking, at what hour did you smoke the first cigarette of your relapse? On the day mentioned above, I smoked my first cigarette
after my quit attempt at hours
How long lasted your last quit attempt?  My last quit attempt lasted
Questions for EX-smokers:
=> Smokers, please click here.
EX-smokers:
What type of tobacco did you smoke mainly, before you quit smoking?
Before quitting, I smoked:
Did you quit smoking abruptly ("cold turkey") or did you first cut down on your cigarette consumption before quitting smoking? 
How many cigarettes did you smoke per day, on average, during the month before you quit smoking? During the month before I quit smoking, I smoked on average cigarettes per day
Are you sure that you are never going to smoke again?
When did you quit smoking? I quit smoking on:
Day:

Month:

Year:

On the day when you quit smoking, at what hour did you smoke your last cigarette? On the day when I quit smoking,
I smoked my last cigarette at hours

If you read French, please indicate which is the best translation for the following items:
If you
do not read French, please click here:
à traduire: La meilleure traduction à votre avis:
Absolument pas d'accord
Plutôt pas d'accord
Plus ou moins d'accord
Plutôt d'accord
Tout à fait d'accord
1- Totally disagree; Mostly disagree; More or less agree; Mostly agree; Totally agree

2- Strongly disagree; Disagree; Undecided; Agree; Strongly agree

3- Strongly disagree; Disagree; Feel neutral; Agree; Strongly agree.

4- Strongly disagree; Do NOT really agree; More or less agree; Generally agree; Fully agree

5- Totally disagree; Do NOT really agree; More or less agree; Agree; Fully agree

63- J'ai de la peine à réfléchir 1- I can hardly think
2- I can't keep my thoughts focused
3- I can't think easily
4- I find it difficult to think
5- I find it difficult to think clearly
6- I find it hard to think clearly
7- I have difficulty to think about things
8- I have trouble reflecting
9- I have trouble thinking
10- I have trouble thinking clearly
11- It's hard to think
12- I have trouble focusing

Please check that you answered to ALL questions

THANKS + + +

Note: Your answers will be stored on a computer file, for statistical analyses. Information enabling identification of survey participants will be accessed only by Jean-Francois Etter, PhD , who is in charge of this survey, and by one computer expert under his supervision; this information will not be made available to any one else. Archived data will also be used for organizing the follow-up of participants. If you do not want us to retain your answers on file, do not click on the button above.

Created by par , Dec. 17, 2002.