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Over the last two weeks, have you noticed the following:

(for each line click the circle that best applies to you)  Not at all Rarely Sometimes Often Most of the time
1.  I feel sad, down in the dumps or unhappy          
2.  I can’t concentrate or focus          
3.  Nothing seems to give me much pleasure          
4.  I feel tired; have no energy          
5.  I have had thoughts of suicide          
6.  Changes in sleeping patterns:          
a I have difficulty sleeping          
b I have been sleeping too much          
7.  Changes in appetite:          
a.  I have lost some appetite          
b.  I have been eating more          
8.  I feel tense, anxious or can’t sit still          
9.  I feel worried or fearful          
10.  I have attacks of anxiety or panic          
11.  I worry about dying or losing control          
12.  I am nervous or shaky in social situations          
13.  I have nightmares or flashbacks          
14.  I am jumpy or feel startled easily          
15.  I avoid places that strongly remind me of a bad experience          
16.  I feel dull, numb, or detached          
17.  I can’t get certain thoughts out of my mind          
18.  I feel I must repeat certain acts or rituals          
19.  I feel the need to check and recheck things          

At any time in your life have there been phases or periods when you have:

20.  Had more energy than usual          
21.  Felt unusually irritable or angry          
22.  Felt unusually excited, revved up or high          
23.  Needed less sleep than usual          

Indicate whether any of the above symptoms:

24.  Interferes with work or school          
25.  Affects my relationships with friends or family          
26.  Has led to my using alcohol to get by          
27.  Has led to my using drugs          

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This form is not a diagnostic instrument and is to be used solely within the context of your medical treatment with your physician or other health care provider. The maker and provider of this form disclaims any liability, loss, or risk incurred as a consequence, directly or indirectly, from the use and application of any of this material. WhatsMyM3™ V.03.06 Copyright © 2002-2012 by M3 Information™, The M-3 Checklist and WhatsMyM3.com are free for personal home use. For any other uses, including clinical., educational, non-profit, hospital research, or for-profit settings please contact mail@m-3information.com. No further reproduction or distribution, or reverse engineering is permitted without written permission from M3 Information. Patent Pending.