First Name
*
Last Name
Today's Date
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1. Falling Asleep
0 - I never take longer than 30 minutes to fall asleep
1 - I take at least 30 minutes to fall asleep, less than half the time
2 - I take at least 30 minutes to fall asleep, more than half the time
3 - I take more than 60 minutes to fall asleep, more than half the time
2. Sleep During the Night
0 - I do not wake up at night
1 - I have a restless, light sleep with a few brief awakenings each night
2 - I wake up at least once a night, but I go back to sleep easily
3 - I awaken more than once a night and stay awake for 20 minutes or more, more than half the time
3. Waking up too early
0 - Most of the time, I awaken no more than 30 minutes before I need to get up
1 - More than half the time, I awaken more than 30 minutes before I need to get up
2 - I almost always awaken at least one hour or so before I need to, but I go back to sleep eventually
3 - I awaken at least one hour before I need to, and can’t go back to sleep
4. Sleeping too much
0 - I sleep no longer than 7-8 hours/night, without napping during the day
1 - I sleep no longer than 10 hours in a 24-hour period including naps
2 - I sleep no longer than 12 hours in a 24-hour period including naps
3 - I sleep longer than 12 hours in a 24-hour period including naps
5. Feeling Sad
0 - I do not feel sad
1 - I feel sad less than half the time
2 - I feel sad more than half the time
3 - I feel sad nearly all the time
6. Decreased appetite (Complete either 6 or 7, NOT both)
0 - There is no change in my usual appetite
1 - I eat somewhat less often or lesser amounts of food than usual
2 - I eat much less than usual and only with personal effort
3 - I rarely eat within a 24-hour period, and only with extreme personal effort or when others persuade me to eat
7. Increased Appetite (Complete either 6 or 7, NOT both)
0 - There is no change from my usual appetite
1 - I feel a need to eat more frequently than usual
2 - I regularly eat more often and/or great amounts of food than usual
3 - I feel driven to overeat both at mealtime and between meals
8. Decreased weight (Complete either 8 or 9, NOT both)
0 - I have not had a change in my weight
1 - I feel as if I have had a slight weight loss
2 - I have lost 2 pounds or more
3 - I have lost 5 pounds or more
9. Increased weight (Complete either 8 or 9, NOT both)
0 - I have not had a change in my weight
1 - I feel as if I have had a slight weight gain
2 - I have gained 2 pounds or more
3 - I have gained 5 pounds or more
10. Concentration/Decision Making
0 - There is no change in my usual capacity to concentrate or make decisions
1 - I occasionally feel indecisive or find that my attention wanders
2 - Most of the time, I struggle to focus my attention or to make decisions
3 - I cannot concentrate well enough to read or cannot make even minor decisions
11. View of Myself
0 - I see myself as equally worthwhile and deserving as other people
1 - I am more self-blaming than usual
2 - I largely believe that I cause problems for others
3 - I think almost constantly about major and minor defects in myself
12. Thoughts of death or suicide
0 - I do not think of suicide or death
1 - I feel that life is empty or wonder if it’s worth living
2 - I think of suicide or death several times a week for several minutes
3 - I think of suicide or death several times a day in some detail, or I have made specific plans for suicide or have actually tried to take my life
13. General Interest
0 - There is no change from usual in how interested I am in other people or activities
1 - I notice that I am less interested in people or activities
2 - I find I have interest in only one or two of my formerly pursued activities
3 - I have virtually no interested in formerly pursued activities
14. Energy Level
0 - There is no change in my usual level of energy
1 - I get tired more easily than usual
2 - I have to make a big effort to start or finish my usual daily activities (ex. shopping, homework, cooking, or going to work)
3 - I really cannot carry out most of my usual daily activities because I just don’t have the energy
15. Feeling Slowed Down
0 - I think, speak, and move at my usual rate of speed
1 - I find that my thinking is slowed down or my voice sounds dull or flat
2 - It takes me several seconds to respond to most questions and I’m sure my thinking is slowed
3 - I am often unable to respond to questions without extreme effort
16. Feeling Restless
0 - I do not feel restless
1 - I’m often fidgety, wringing my hands, or need to shift how I am sitting
2 - I have impulses to move about and am quite restless
3 - At times, I am unable to stay seated and need to pace around
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