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1. In the past 4 weeks, about how often did you feel tired out for no good reason?
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(1) None of the time
(2) A little of the time
(3) Some of the time
(4) Most of the time
(5) All of the time
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2. In the past 4 weeks, about how often did you feel nervous?
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(1) None of the time
(2) A little of the time
(3) Some of the time
(4) Most of the time
(5) All of the time
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3. In the past 4 weeks, about how often did you feel so nervous that nothing could calm you down?
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(1) None of the time
(2) A little of the time
(3) Some of the time
(4) Most of the time
(5) All of the time
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4. In the past 4 weeks, about how often did you feel hopeless?
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(1) None of the time
(2) A little of the time
(3) Some of the time
(4) Most of the time
(5) All of the time
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5. In the past 4 weeks, about how often did you feel restless or fidgety?
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(1) None of the time
(2) A little of the time
(3) Some of the time
(4) Most of the time
(5) All of the time
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6. In the past 4 weeks, about how often did you feel so restless you could not sit still?
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(1) None of the time
(2) A little of the time
(3) Some of the time
(4) Most of the time
(5) All of the time
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7. In the past 4 weeks, about how often did you feel depressed?
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(1) None of the time
(2) A little of the time
(3) Some of the time
(4) Most of the time
(5) All of the time
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8. In the past 4 weeks, about how often did you feel that everything was an effort?
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(1) None of the time
(2) A little of the time
(3) Some of the time
(4) Most of the time
(5) All of the time
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9. In the past 4 weeks, about how often did you feel so sad that nothing could cheer you up?
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(1) None of the time
(2) A little of the time
(3) Some of the time
(4) Most of the time
(5) All of the time
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10. In the past 4 weeks, about how often did you feel worthless?
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(1) None of the time
(2) A little of the time
(3) Some of the time
(4) Most of the time
(5) All of the time
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Name:
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Email Address:
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