Name: Occupation: Marital Status: _______ Age: _____ Sex: _ Education: - Instructions: This questionnaire consists of 21 groups of statements. Please read each group of statements carefully, and then pick out the one statement in each group that best describes the way you have been feeling during the past two weeks, including today. Circle the number beside the statement you have picked. If several statements in the group seem to apply equally well, circle the highest number for that group. Be sure that you do not choose more than one statement for any group, icluding Item 16 (Changes in Sleeping Pattern) or Item 18 (Changes in Appetite) 1. Sadness 0 Ido not feel sad. 1 [feel sad much of the time. 2 Lam sad all the time. 3. Lam so sad or unhappy that I can’t stand it. 2. Pessimism 01am not discouraged about my future. 1 [feel more discouraged about my future than I used to be. 2 Ido not expect things to work out for me. 3. feel my future is hopeless and will only get worse. 3. Past Failure 0 Ido not feel like a failure. Thave failed more than I should have. As I look back, I see a lot of failures. 1 feel 1 am a total failure as a person. 4. Loss of Pleasure 0 Lget as much pleasure as I ever did from the things I enjoy. 1 [don’t enjoy things as much as I used to. | 2. get very litte pleasure from the things I used | to enjoy | 3. Lcan’t get any pleasure from the things I used to | | enjoy Feelings | 0 I don’t feel particularly guilty. 1 feel guilty over many things I have done or | should have done. I feel quite guilty most of the time. 3 [feel guilty all of the time. . Punishment Feelings 0 I don’t feel I am being punished. 11 feel I may be punished. 2 Lexpect to be punished. 3° I feel | am being punished. Self-Dislike [ feel the same about myself as ever. Thave lost confidence in myself. Lam disappointed in myself. I dislike myself 8. Self-Criticainess I don’t criticize or blame myself more than usual. Tam more critical of myself than I used to be. Icriticize myself for all of my faults. blame myself for everything bad that happens. 8 foe Thoughts or Wishes Idon’t have any thoughts of killing myself, t Thave thoughts of killing myself, but I would not carry them out. 2 Lwould like to kill myself. 3. I would kill myself if I had the chance. 10. Crying 0 Idon’t ery any more than I used to. | 1 Lery more than I used to. 2 Lory over every little thing, 3. [feel like crying, but I can’t. PEA 37 38 39 40 41 42.43.44 45464748 BCDE Copyright © 1996 Aaron T. Beck. Al rights reserved, For inquiries or reordering, call: 800.627.7271 or goto www ren Scanned with CamScanner11. Agitation 0 Lam no more restless or wound up than usual. 1 fee! more restless or wound up than usual. 2 Lam so restless or agitated that it’s hard to stay still 3. Lam so restless or agitated that I have to keep moving or doing something. 12, Loss of Interest 0 Thave not lost interest in other people or activities, 1 Lam less interested in other people or things than before. 2 Thave lost most of my interest in other people or things. 3 It’s hard to get interested in anything. 13. Indecisiveness 0 Imake decisions about as well as ever. 1 [find it more difficult to make decisions than usual 2 Thave much greater difficulty in making decisions than I used to, 3. Ihave trouble making any decisions. 14. Worthlessness I do not fee! 1 am worthles I don’t consider myself as worthwhile and useful as | used to. I feel more worthless as compared to other people. | feel utterly worthless. 15. Loss of Energy 0 Thave as much energy as ever. 1 Thave less energy than I used to have. 2 [don’t have enough energy to do very much. 3. I don’t have enough energy to do anything. 16. Changes in Sleeping Pattern 0. Thave not experienced any change in my sleeping patter, Ta Tsleep somewhat more than usual 1b_Isleep somewhat less than usual 2a Tsleep a lot more than usual, 2b_Isleep a lot less than usual. 3a, Tsleep most of the day. 3b I wake up 1-2 hours early and can’t get back to sleep, 18. Changes in Appetite 19. Concentration Difficulty 20. Tiredness or Fatigue a. 17. Irritability 0 Tam no more irritable than usual 1 Lam more irritable than usual 2 Lam much more irritable than usual 3° Laminritable all the time. 0 Thave not experienced any change in my appetite. Ta My appetite is somewhat less than usual Ib_My appetite is somewhat greater than usual. 2a_ My appetite is much less than before My appetite is much greater than usual 3a Thave no appetite at al. 3b I crave food all the time. 0 can concentrate as well as ever. 1 Tcan’t concentrate as well as usual 2 It’shard to keep my mind on anything for very long. 3° [find I can’t concentrate on anything, 0 Lam no more tired or fatigued than usual. 1 I get more tired or fatigued more easily than usual. 2 Lam too tired or fatigued to do a lot of the things Lused to do. 3 Lam too tired or fatigued to do most of the things I used to do, Loss of Interest in Sex 0 Ihave not noticed any recent change in my interest in sex. 1 Tam less interested in sex than I used to be. Tam much less interested in sex now. Thave lost interest in sex completely. NOTICE: This tormis printed with green and Black ink. your copy does nat appear tis way, thas been photo- oped in violation o copyright laws Subtotal Page 2 Subtotal Page 1 Total Score Scanned with CamScanner