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Nam.: · _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ __ Marital Status: Age: _ _ _ Sex: _ _

Occu p:1t io11" _ _ _ _ _ _ _ _ _ _ _ __ _ _ __ Education : _ _ _ _ _ __ _ _ _ _ _ _ _ _ __

Ins tructions : 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 lo apply equally well, circle the highest number for that group. Be sure that you do not choose more than one
statement for any group, including Item 16 (Changes in Sleeping Pattern) or Item 18 (Changes in Appetite).

1. Sadness 6. Punishment Feelings

0 I do not feel sad. 0 I don 't feel J am being punished.
I feel sad much of the time. I feel I may be punished.
2 I am sad all the time. 2 I expect to be punished.
J I am so sad or unhappy that I can't stand it. 3 J feel I am being punished.

2. Pessimism 7. Self-Dislike
0 I am not discouraged about my future. 0 I feel the same about myself as ever.
I feel more discouraged about my future than I I I have lost confidence in myself.
used to be. 2 I am disappointed in myself.
2 I do not expect things to work out for me. 3 I dislike myself.
J I feel my future is hopeless and will only get
worse. 8. Self-Criticalness
0 I don 't criticize or blame myself more than usual.
3. Past Failure I am more critical of myself than I used to be.
0 I do not feel like a failure. 2 I criticize myself for all ofmy faults.
l I have failed more than I should have. 3 J blame myself for everything bad that happens.
2 As I look back, I see a lot of failures.
J I feel I am a total failure as a person. 9. Suicidal Thoughts or Wishes
0 I don' t have any thoughts of killing myself.
4. Loss of Pleasure I have thoughts of killing myself, but I would
0 I get as much pleasure as I ever did from the not carry them out.
things I enjoy. 2 I would like to kill myself.
I I don't enjoy things as much as I used to. 3 I would kill myself ifl had the chance.
2 I get very little pleasure from the things I used
to enjoy. 10. Crying
J I can 't get any pleasure from the things I used to 0 I don ' t cry any more than I used to.
enjoy.
I I cry more than I used to.
2 I cry over every little thing.
5. Guilty Feelings
3 I feel like crying, but I can't.
O I don ' t feel particularly guilty.
I feel guilty over many things l have done or
should have done.
2 I feel quite guilty most of the time.
3 I feel guilty all of the time.

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 1 11 . Agitation
1
17. Irritability
0 I am no more restless or wound up than usual. 0 I am no more irritable than usual.
I feel more re tless or wound up than usual. I I am more irritable than usual.
2 I a m so restless or agitated that it' s hard to stay 2 1 am much more mitable than usual.
st i11.
3 l am irritable all the time.
3 I am o restless or agi tated that I have to keep
moving or doing something.
18. Changes in Appetite \
0 l have not experienced any change in my
1 12. Loss of Interest
appetite. \
0 I hav~ _not lost interest in other people or :--:-:----.--:-------:---:-----:--
1a My appetite is somewhat less than usual.
ac11v1lles.
I b My appetite 1s somewhat greater than usual.
l am less interested in other people or things
than before. 2a My appetite is much less than before.
;; 2 l hav_e lost most of my interest 111 other peopl e 2b My appetite is much greater than usual.
or thmgs . 3a I have no appetite at all.
3 lt' s hard to get interested in anything. 3b I crave food all the time .

13. Indecisiveness 19. Concentration Difficulty

0 I make dec1s1ons about as well as ever. 0 I can concentrate as well as ever.
I find it more difficult to make decisions than I I can't concentrate as well as usual.
usual . 2 It' s hard to keep my mind on anything for
2 I have much greater difficulty in making very long.
decisions than I used to. 3 I find I can 't concentrate on anything.
3 I have trouble making any decisions.
20. Tiredness or Fatigue
14. Worthlessness 0 I am no more tired or fatigued than usual.
0 I do not feel I am worthless. I get more tired or fatigued more easily than
I don ' t consider myself as worthwhile and useful usual.
as I used to. 2 I am too tired or fatigued to do a lot of the things
2 I feel more worthless as compared to other I used to do.
people. 3 I am too tired or fatigued to do most of the
3 I feel utterly worthless . things I used to do.

15. Loss of Energy 21 . loss of Interest in Sex

0 I have as much energy as ever. 0 I have not noticed any recent change in my
interest in sex.
1 I have less energy than I used to have.
1 I am less interested in sex than I used to be.
2 I don ' t have enough energy to do very much.
2 I am much less interested in sex now.
3 I don ' t have enough energy to do anything.
3 I have lost interest in sex completely.

16. Changes in Sleeping Pattern

O I have not experienced any change in my
sleeping pattern.
1a I sleep somewhat more than usual.
1b I sleep somewhat less than usual.
2a I sleep a lot more than usual.
2b r sleep a lot less than usual.
3a I sleep most of the day.
3b I wake up 1-2 hours early and can't get back
to sleep .

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