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1 |
[record_id] |
Record ID |
text |
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2 |
[participant_id_and_name_1] |
Participant id and name
प्रतिभागी आईडी और नाम
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text |
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3 |
[day] |
Day
दिन
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text |
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4 |
[date] |
Date
तारीख
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text |
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5 |
[how_long_has_it_been_since] |
How long has it been since you last had a drink of any kind of alcohol?
आपने आखिरी बार किसी भी प्रकार का शराब पेय कब पिया था?
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radio| 1 | Hour(s) ago - कुछ घंटे पहले | | 2 | Day(s) ago- दिन पहले | | 3 | Week(s) ago - सप्ताह पहले | | 4 | Month(s) ago- महीने पहले | | 5 | Year(s) ago-वर्ष पहले |
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6 |
[how] |
Mention the exact duration
कृपया सटीक अवधि बताएं।
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text |
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7 |
[any_difficulty_you_are_fac] |
Are you facing any difficulty post treatment ?
क्या आपको उपचार के बाद किसी प्रकार की कठिनाई का सामना करना पड़ रहा है?
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yesno |
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8 |
[if_yes_please_describe] |
If yes ,please describe
यदि हाँ, तो कृपया वर्णन करें
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text |
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9 |
[any_other_drug_or_substanc] |
Any other drug or substance you are taking now?
क्या आप इस समय कोई अन्य दवा या पदार्थ ले रहे हैं?
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yesno |
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10 |
[alcohol_consumption_questionaire_complete] |
Section Header: Form Status
Complete?
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dropdown| 0 | Incomplete | | 1 | Unverified | | 2 | Complete |
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11 |
[alcohol_craving_questionaire_1] |
Section Header: Alcohol Craving Questionnaire Please indicate how much you agree or disagree with each of the following statements by placing a single checkmark (like this: X) along each line between STRONGLY DISAGREE and STRONGLY AGREE, The closer you place your checkmark to one end or the other indicates the strength of your disagreement or agreement. We are interested in how you are thinking or feeling right now as you are filling out this questionnaire. Please complete every item. शराब की लालसा प्रश्नावली कृपया बताएं कि आप निम्नलिखित कथनों में से प्रत्येक से कितना सहमत या असहमत हैं, इसके लिए आपको अत्यन्त असहमति और अत्यन्त सहमति के बीच उचित पंक्ति पर एक चेकमार्क (जैसे: X) लगाना होगा। आप अपने चेकमार्क को एक छोर या दूसरे छोर के जितना करीब रखेंगे, यह आपकी असहमति या सहमति की मात्रा को दर्शाता है। हमें इस बात में दिलचस्पी है कि आप इस प्रश्नावली को भरते समय अभी क्या सोच रहे हैं या कैसा महसूस कर रहे हैं। कृपया हर आइटम को पूरा करें।
If I had some alcohol, I would probably drink it.
अगर मेरे पास शराब होती तो मैं शायद उसे पी लेता / लेती।
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radio| 1 | Strongly disagree | | 2 | Strongly agree |
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12 |
[alcohol_craving_questionaire_2] |
I miss drinking
मुझे शराब पीने की याद आती है।
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radio| 1 | Strongly disagree | | 2 | Strongly agree |
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13 |
[alcohol_craving_questionaire_3] |
I am not making any plans to drink.
मैं शराब पीने की कोई योजना नहीं बना रहा / रही हूं।
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radio| 1 | Strongly disagree | | 2 | Strongly agree |
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14 |
[alcohol_craving_questionaire_4] |
I could not stop myself from drinking if I had some alcohol here.
अगर मुझे यहां शराब मिल जाती तो मैं खुद को पीने से नहीं रोक पाता / पाती।
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radio| 1 | Strongly disagree | | 2 | Strongly agree |
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15 |
[alcohol_craving_questionaire_5] |
I want to drink so bad, I can almost taste it.
मैं इतनी बुरी तरह पीना चाहता / चाहती हूँ कि मैं लगभग उसका स्वाद महसूस कर सकता / सकती हूँ।
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radio| 1 | Strongly disagree | | 2 | Strongly agree |
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16 |
[alcohol_craving_questionaire_6] |
I would feel less irritable if I used alcohol now.
अगर मैं अब शराब का सेवन करूँ तो मुझे कम चिड़चिड़ापन महसूस होगा।
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radio| 1 | Strongly disagree | | 2 | Strongly agree |
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17 |
[alcohol_craving_questionaire_7] |
If I used alcohol, I would feel less tense.
अगर मैं शराब पीता / पीती तो मुझे कम तनाव महसूस होता।
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radio| 1 | Strongly disagree | | 2 | Strongly agree |
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18 |
[alcohol_craving_questionaire_8] |
Drinking would not be very satisfying.
मुझे शराब पीने से बहुत संतुष्टि नहीं मिलेगी।
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radio| 1 | Strongly disagree | | 2 | Strongly agree |
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19 |
[alcohol_craving_questionaire_9] |
I would feel less restless if I drank alcohol.
अगर मैं शराब पीता / पीती तो मुझे कम बेचैनी महसूस होती।
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radio| 1 | Strongly disagree | | 2 | Strongly agree |
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20 |
[alcohol_craving_questionaire_10] |
If I were using alcohol, I would feel less nervous.
यदि मैं शराब पी रहा/रही होता/होती तो मुझे कम घबराहट महसूस होती।
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radio| 1 | Strongly disagree | | 2 | Strongly agree |
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21 |
[alcohol_craving_questionaire_11] |
It would be easy to pass up the chance to use alcohol.
शराब का सेवन करने का मौका छोड़ना आसान होगा।
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radio| 1 | Strongly disagree | | 2 | Strongly agree |
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22 |
[alcohol_craving_questionaire_12] |
Drinking would put me in a better mood.
शराब पीने से मेरा/मेरी मूड अच्छा हो जाएगा।
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radio| 1 | Strongly disagree | | 2 | Strongly agree |
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23 |
[alcohol_craving_questionaire_complete] |
Section Header: Form Status
Complete?
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dropdown| 0 | Incomplete | | 1 | Unverified | | 2 | Complete |
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24 |
[during_the_past_week_how_o] |
Section Header: Penn Alcohol Craving Scale (PACS)
Please read each item carefully and mark the box that best describes your craving during the past week.
"पेन अल्कोहल क्रेविंग स्केल का उपयोग करके, कृपया प्रत्येक प्रश्न को ध्यान से पढ़ें और पिछले सप्ताह में अपनी शराब की लालसा को सबसे अच्छी तरह से दर्शाने वाले बॉक्स पर निशान लगाएँ।"
During the past week how often have you thought about drinking or about how good a drink would make you feel?
पिछले हफ़्ते में आपने कितनी बार शराब पीने के बारे में सोचा है या इस बारे में कि शराब पीने से आपको कितना अच्छा महसूस होगा?
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radio| 0 | Never (0 times during the past week) | | 1 | Rarely (1 to 2 times during the past week) | | 2 | Occasionally (3 to 4 times during the past week) | | 3 | Sometimes (5 to 10 times during the past week or 1 to 2 times per day) | | 4 | Often (11 to 20 times during the past week or 2 to 3 times per day) | | 5 | Most of the time (20 to 40 times during the past week or 3 to 6 times per day) | | 6 | Nearly all of the time (more than 40 times during the past week or more than 6 times per day) |
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25 |
[at_its_most_severe_point_h] |
At its most severe point, how strong was your craving during the past week?
पिछले हफ़्ते में शराब पीने की आपकी इच्छा सबसे ज़्यादा तीव्र थी?
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radio| 0 | None at all | | 1 | Slight, that is a very mild urge | | 2 | Mild urge | | 3 | Moderate urge | | 4 | Strong urge, but easily controlled | | 5 | Strong urge and difficult to control | | 6 | Strong urge and would have drunk alcohol if it were available |
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26 |
[at_its_most_severe_point_h_2] |
During the past week how much time have you spent thinking about drinking or about how good a drink would make you feel?
पिछले हफ़्ते में आपने शराब पीने के बारे में या इस बारे में कि शराब पीने से आपको कितना अच्छा महसूस होगा, कितना समय बिताया है?
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radio| 0 | None at all | | 1 | Less than 20 minutes | | 2 | 21 to 45 minutes | | 3 | 46 to 90 minutes | | 4 | 90 minutes to 3 hours | | 5 | Between 3 to 6 hours | | 6 | More than 6 hours |
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27 |
[at_its_most_severe_point_h_3] |
During the past week how difficult would it have been to resist taking a drink if you had known a bottle were in your house?
पिछले हफ़्ते में अगर आपको पता होता कि आपके घर में शराब की बोतल है, तो शराब पीने से खुद को रोकना कितना मुश्किल होता?
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radio| 0 | Not difficult at all | | 1 | Very mildly difficult | | 2 | Mildly difficult | | 3 | Moderately difficult | | 4 | Very difficult | | 5 | Extremely difficult | | 6 | Would not be able to resist |
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28 |
[at_its_most_severe_point_h_4] |
Keeping in mind your responses to the previous questions, please rate your overall average alcohol craving for the past week.
पिछले सवालों के जवाबों को ध्यान में रखते हुए, कृपया पिछले हफ़्ते की अपनी औसत शराब की इच्छा को रेट करें।
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radio| 0 | Never thought about drinking and never had the urge to drink | | 1 | Rarely thought about drinking and rarely had the urge to drink | | 2 | Occasionally thought about drinking and occasionally had the urge to drink | | 3 | Sometimes thought about drinking and sometimes had the urge to drink | | 4 | Often thought about drinking and often had the urge to drink | | 5 | Thought about drinking most of the time and had the urge to drink most of the time | | 6 | Thought about drinking nearly all of the time and had the urge to drink nearly all of the time |
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29 |
[total_score] |
Total Score |
calc
Calculation: [during_the_past_week_how_o] + [at_its_most_severe_point_h] + [at_its_most_severe_point_h_2] + [at_its_most_severe_point_h_3] + [at_its_most_severe_point_h_4] |
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30 |
[penn_alcohol_craving_scale_pacs_complete] |
Section Header: Form Status
Complete?
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dropdown| 0 | Incomplete | | 1 | Unverified | | 2 | Complete |
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31 |
[were_you_able_to_use_it] |
Were you able to use the odor stick ?
क्या आप गंध पहचानने वाली छड़ी का उपयोग कर पाए?
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yesno |
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32 |
[how_many_times_you_used_it] |
How many times during the day you used it ?
आपने दिन में कितनी बार इसका इस्तेमाल किया?
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text |
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33 |
[how_long_did_you_use_it_me] |
How long did you use it ?(Mention the duration)
आपने इसका उपयोग कितने समय तक किया? (अवधि का उल्लेख करें)
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dropdown| 1 | 10 minutes - 10 मिनट | | 2 | 15 minutes - 15 मिनट | | 3 | 20 minutes - 20 मिनट | | 4 | 25 minutes - 25 मिनट | | 5 | 30 minutes- 30 मिनट | | 6 | 35 minutes-35 मिनट | | 7 | 40 minutes-40 मिनट |
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34 |
[how_did_you_feel_after_usi] |
How did you feel after using it ?
इसे इस्तेमाल करने के बाद आपको कैसा लगा?
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slider (Min: 0, Max: 10)
Slider labels: 0(worst ), , 10(best)
Custom alignment: RH |
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35 |
[how_did_you_feel_after_usi_2] |
How pleasant is the odor?
इसकी गंध कितनी सुखद है?
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slider (Min: 0, Max: 10)
Slider labels: 0(unpleasant), , 10(pleasant)
Custom alignment: RH |
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36 |
[how_did_you_feel_after_usi_3] |
How intense is the odor?
गंध कितनी तीव्र है?
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slider (Min: 0, Max: 10)
Slider labels: 0(weak), , 10(strong)
Custom alignment: RH |
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37 |
[write_4_emotion_evoked_by] |
Write 4 emotion evoked by this odor
इस गंध से उत्पन्न होने वाली 4 भावनाओं को लिखिए
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text
Custom alignment: RH |
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38 |
[rate_the_emotional_intensi] |
Rate the emotional intensity-emotion 1
भावनात्मक तीव्रता का मूल्यांकन करें-भावना 1
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slider (Min: 0, Max: 10)
Slider labels: 0(less), , 10(more)
Custom alignment: RH |
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39 |
[rate_the_emotional_intensi_2] |
Rate the emotional intensity-emotion 2
भावनात्मक तीव्रता का मूल्यांकन करें-भावना 2
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slider (Min: 0, Max: 10)
Slider labels: 0(less), , 10(more)
Custom alignment: RH |
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40 |
[rate_the_emotional_intensi_3] |
Rate the emotional intensity-emotion 3
भावनात्मक तीव्रता का मूल्यांकन करें-भावना 3
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slider (Min: 0, Max: 10)
Slider labels: 0(less), , 10(more)
Custom alignment: RH |
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41 |
[rate_the_emotional_intensi_4] |
Rate the emotional intensity-Emotion 4
भावनात्मक तीव्रता का मूल्यांकन करें-भावना 4
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slider (Min: 0, Max: 10)
Slider labels: 0(less), , 10(more)
Custom alignment: RH |
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42 |
[rate_the_emotional_intensi_5] |
How tense or relaxed did you feel?
आपको कितना तनाव या आराम महसूस हुआ?
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slider (Min: 0, Max: 10)
Slider labels: 0(tense), , 10(relaxed)
Custom alignment: RH |
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43 |
[aroma_questions_complete] |
Section Header: Form Status
Complete?
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dropdown| 0 | Incomplete | | 1 | Unverified | | 2 | Complete |
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