| How true was this for you lately? Rate 0 - 10 |
Frequency | Intensity | Duration | Total |
|
Worry (without reasonable cause) |
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Futility; feelings of uselessness |
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Sad mood (for no reason, over little things) |
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Feelings of hopelessness or pessimism |
|
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|
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Feelings of helplessness or despair |
|
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|
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Guilty feelings (for no reason) |
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|
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Dwelling on the past |
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Irritability (angry even over little things) |
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|
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|
Conviction that your endeavors are meaningless |
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|
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Unable to concentrate, make decisions, study |
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Feeling angry, sullen, bitter, resentful |
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Anxious |
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Decreased thought processes |
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Hypochondria |
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Sense of dread and fear of dying |
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|
|
|
| How true was this for you lately? Rate 0 - 10 |
Frequency | Intensity | Duration | Total |
|
Change in weight during past two months |
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|
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Fatigue, low level of energy |
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Sleep disturbance, insomnia, early awakenings |
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Confusion, memory lapses |
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Decrease in sex drive |
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Crying spells, or feeling like crying |
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Apathy, loss of motivation |
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Loss of interest in favorite things and activities |
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Poor grooming, sloppy appearance, unkempt |
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Withdrawal, feeling isolated
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Loss of sense of humor, difficulty in laughing |
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Introspection and introversion, self-centered |
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Inferiority feelings |
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Feeling unloved, unwanted, unappreciated |
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Feeling worthless |
|
|
|
|
| How true was this for you lately? Rate 0 - 10 |
Frequency | Intensity | Duration | Total |
|
Depersonalization (leaving your body) |
|
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|
|
|
Lack of warm feelings, emotions, or interests
|
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|
|
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Fear of rejection & desire to be close |
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Clinging behavior |
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|
Defensiveness, denial, displacement |
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|
Paranoid, afraid people are mad at you |
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|
|
Masochism (seeking painful experiences) |
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Headaches |
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Back pain |
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Indigestion, constipation, or heartburn |
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Other aches and pains |
|
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|
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Suicidal thoughts or escape fantasies |
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Cutting on or hurting yourself |
|
|
|
|
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A plan to commit suicide |
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|
An attempt to commit suicide |
|
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|
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| Total factors selected:
out of 45 |
Total score: |
|
|
