Informed Consent

We are clinical psychology student of BS at Department of Psychology, University of

Sargodha. We are conducting the present research level of emotional distress, illness
perception and body image in patients with somatic symptoms. For this purpose you
will have to complete following questioners. Your identity and information obtained
from you during this research will remain confidential and the data obtained from you
will only be used for research purpose.

You have the right to refuse to participate in this research. You may also
withdraw your data at any stage of the research. However there is no physical,
psychological, or social risk in participating in this study. Your cooperation is highly
valuable and will assist to advance scientific knowledge.

I am willing to participate in the study and I have no objection to above

mentioned process of publication of information provided by me.

_______________________

(Signature)

Thank you!

Department of Psychology, University of Sargodha.

Part A. Please provide the following information.

Gender: __________________________ Age: ____________________________
Marital Status _____________________ Education ________________________
Family income: ____________________ Family System: ____________________
Residence (Urban, Rural) ____________
 Part A. The statements below concern your personal reactions to a number of situations. No
two statements are exactly alike, so consider each statement carefully before answering. It is
important that you answer as frankly and as honestly as you can. Please rate from 0 – 10
No affect at all Severely affects my
life

0 1 2 3 4 5 6 7 8 9 10

Sr. Statements 0 1 2 3 4 5 6 7 8 9 10
no.
1 How much does your illness affect your life?

2 How long do you think your illness will continue?

3 How much control do you feel you have over your

illness?
4 How much do you think your treatment can help
your illness?
5 How much do you experience symptoms from
your illness?
6 How concerned are you about your illness?

7 How well do you feel you understand your illness?

8 How much does your illness affect you

emotionally? (E.g. does it make you angry, scared,
upset or depressed?

Part B. Circle response based on your experience over the preceding four weeks.

Strongly Disagree Mildly Mildly Agree Strongly

Disagree Moderately Disagree Agree Moderately Agree
0 1 2 3 4 5

Sr. Statements 0 1 2 3 4 5
no
1 I often feel quite anxious.
2 I often feel quite depressed
3 I often feel quite irritable and angry

4 I no longer enjoy activities I previously found

pleasurable
5 I have low self-esteem or self-confidence
 0 1 2 3 4 5
6 I generally feel physically tense

7 I often feel agitated or restless

8 I often feel physically tired or fatigued

9 I have problems concentrating

10 I have problems sleeping

Part C. Please rate how much you satisfied that following statements describe you

Not at all A little Quit a bit Very much

1 2 3 4

Sr. Statements 1 2 3 4
no
1 Have you been feeling self-conscious about your appearance?

2 Have you felt less physically attractive as a result of your disease or

treatment?
3 Have you been dissatisfied with your appearance when dressed?

4 Have you been feeling less feminine/masculine as a result of your

disease or treatment?
5 Did you find it difficult to look at yourself naked?

6 Have you been feeling less sexually attractive as a result of your

disease or treatment?
7 Did you avoid people because of the way you felt about your
appearance?
8 Have you been feeling the treatment has left your body less whole?

9 Have you felt dissatisfied with your body?

10 Have you been dissatisfied with the appearance of your scar?