| NAME:___________________________________________ |
DATE:______________________ |
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Over the last 2 weeks, how often have you been
bothered by any of the following problems?
(use “ ” to indicate your answer)
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| 1. |
Little interest or pleasure in doing things |
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0 |
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1 |
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2 |
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3 |
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| 2. |
Feeling down, depressed, or hopeless |
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0 |
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1 |
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2 |
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3 |
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| 3. |
Trouble falling or staying asleep,
or sleeping too much |
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0 |
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1 |
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2 |
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3 |
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| 4. |
Feeling tired or having little energy |
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0 |
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1 |
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2 |
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3 |
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| 5. |
Poor appetite or overeating |
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0 |
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1 |
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2 |
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3 |
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| 6. |
Feeling bad about yourself—or that
you are a failure or have let yourself
or your family down |
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0 |
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1 |
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2 |
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3 |
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| 7. |
Trouble concentrating on things, such as reading the
newspaper or watching television |
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0 |
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1 |
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2 |
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3 |
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| 8. |
Moving or speaking so slowly that other people could
have noticed. Or the opposite—being so fidgety
or restless that you have been moving around a lot
more than usual |
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0 |
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1 |
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2 |
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3 |
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| 9. |
Thoughts that you would be better off dead,
or of hurting yourself in some way |
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0 |
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1 |
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2 |
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3 |
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10. |
If you checked off any problems, how
difficult have these problems made it for
you to do your work, take care of things at
home, or get along with other people?
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Not difficult at all |
_________ |
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Somewhat difficult |
_________ |
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Very difficult |
_________ |
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Extremely difficult |
_________ |
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