Version May 2024
Name or ID: ________________________________ Date: _____________ | |
| Check the one response to each item that best describes you for the past seven days. | |
| During the past seven days... | |
| 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 of the time. |
| Please complete either 6 or 7 (not both). | |
| 6. Decreased appetite | |
| ____ 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. |
| OR | |
| 7. Increased appetite | |
| ____ 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 greater amounts of food than usual. |
| ____ 3 | I feel driven to overeat both at mealtime and between meals. |
| Please complete either 8 or 9 (not both). | |
| 8. Decreased weight (within the last two weeks) | |
| ____ 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. |
| OR | |
| 9. Increased weight (within the last two weeks) | |
| ____ 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 interest 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 (for example, 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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