Please answer the questions honestly, and choose the response that
best describes how you've been feeling over the past two monthes
1. Age:
2. Gender:
a) Male
b) Female
3. Year of study:
4. Academic program:
1. During the past month, how often have you had trouble sleeping because you couldn't fall
asleep?
a) Not during the past month
b) Less than once a week
c) Once or twice a week
d) Three or more times a week
2. During the past month, how often have you had trouble sleeping because you woke up in the
middle of the night or early morning?
a) Not during the past month
b) Less than once a week
c) Once or twice a week
d) Three or more times a week
3. During the past month, how often have you taken medication to help you sleep?
a) Not during the past month
b) Less than once a week
c) Once or twice a week
d) Three or more times a week
4. During the past month, how would you rate the overall quality of your sleep?
a) Very good
b) Fairly good
c) Fairly bad
d) Very bad
5. During the past month, how often have you felt tired or groggy upon waking?
a) Not during the past month
b) Less than once a week
c) Once or twice a week
d) Three or more times a week
6. During the past month, how often have you had difficulty staying awake during the day?
a) Not during the past month
b) Less than once a week
c) Once or twice a week
d) Three or more times a week
7. During the past month, how often have you experienced bad dreams?
a) Not during the past month
b) Less than once a week
c) Once or twice a week
d) Three or more times a week
8. During the past month, how long has it usually taken you to fall asleep?
a) Less than 15 minutes
b) 15-30 minutes
c) 30-60 minutes
d) More than 60 minutes
9. During the past month, how many hours of sleep have you usually gotten per night?
a) Less than 5 hours
b) 5-6 hours
c) 6-7 hours
d) More than 7 hours
10. During the past month, how often have you had trouble sleeping because you woke up too
early and couldn't fall back asleep?
a) Not during the past month
b) Less than once a week
c) Once or twice a week
d) Three or more times a week
11. I often feel overwhelmed by the amount of academic work I have to do.
a) Strongly Disagree
b) Disagree
c) Neutral
d) Agree
e) Strongly Agree
12. I worry that I won't be able to meet the expectations of my professors.
a) Strongly Disagree
b) Disagree
c) Neutral
d) Agree
e) Strongly Agree
13. I put a lot of pressure on myself to get good grades.
a) Strongly Disagree
b) Disagree
c) Neutral
14. I often feel anxious about meeting deadlines for assignments and exams.
a) Strongly Disagree
b) Disagree
c) Neutral
d) Agree
e) Strongly Agree
15. I feel stressed when I think about my academic performance.
a) Strongly Disagree
b) Disagree
c) Neutral
d) Agree
e) Strongly Agree
16. I expect myself to excel academically, even if it means sacrificing other aspects of my life.
a) Strongly Disagree
b) Disagree
c) Neutral
d) Agree
e) Strongly Agree
17. I feel like I need to be perfect in my academic work.
a) Strongly Disagree
b) Disagree
c) Neutral
d) Agree
e) Strongly Agree
18. I feel like my professors expect too much from me.
a) Strongly Disagree
b) Disagree
c) Neutral
d) Agree
e) Strongly Agree
19. I feel like I'm in competition with my peers for grades and academic recognition.
a) Strongly Disagree
b) Disagree
c) Neutral
d) Agree
e) Strongly Agree
20. I often feel burned out from trying to keep up with my academic workload.
a) Strongly Disagree
b) Disagree
c) Neutral
d) Agree
e) Strongly Agree
21. : How have you been feeling lately?
0-I do not feel sad.
1 - I feel sad.
2 - I feel sad and unhappy.
3 - I feel very sad and unhappy.
22. Pessimism: What do you think about the future?
0 - I am hopeful about the future.
1 - I feel discouraged about the future.
2 - I feel pessimistic about the future.
3 - I feel very pessimistic about the future.
23. Past Failure: How do you feel about your past accomplishments?
0 - I am satisfied with my past accomplishments.
1 - I am dissatisfied with my past accomplishments.
2 - I feel I have failed in my past accomplishments.
3 - I feel I have failed completely in my past accomplishments.
24. Loss of Pleasure: How do you feel about activities you used to enjoy?
0 - I get as much pleasure as I ever did from activities.
1 - I get less pleasure than I used to from activities.
2 - I get much less pleasure than I used to from activities.
3 - I get almost no pleasure from activities.
25. Guilty Feelings: How do you feel about yourself?
0 - I do not feel guilty.
1 - I feel guilty.
2 - I feel very guilty.
3 - I feel extremely guilty.
26. Punishment Feelings: Do you feel you are being punished?
0 - I do not feel I am being punished.
1 - I feel I am being punished.
2 - I feel I am being severely punished.
3 - I feel I am being very severely punished.
27. Self-Dislike: How do you feel about yourself?
0 - I do not feel I dislike myself.
1 - I feel I dislike myself.
2 - I feel I strongly dislike myself.
3 - I feel I very strongly dislike myself.
28. Self-Accusation: Do you blame yourself for things?
0 - I do not blame myself for things.
1 - I blame myself for some things.
2 - I blame myself for many things.
3 - I blame myself for everything.
29. Suicidal Thoughts: Have you had thoughts of harming yourself?
0 - I do not have any thoughts of harming myself.
1 - I have thoughts of harming myself, but I would not carry them out.
2 - I have thoughts of harming myself, and I might carry them out.
3 - I have definite plans to harm myself.
30. Crying: How often do you cry?
0 - I do not cry at all.
1 - I cry occasionally.
2 - I cry more than occasionally.
3 - I cry almost all the time.