• Not at all
  • Rarely
  • Sometimes
  • Often
  • Most of the time
  1. Over the last two weeks, have you noticed the following:
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
  1. At any time in your life OR since you last took this test 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
  1. 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