Your Clinician*

Name*

First Last

Date*

Instructions:
This questionnaire consists of 21 groups of statements. Please read each group of statements carefully, and then choose 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 chosen. If several statements in the group seem to 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).

Sadness*

Pessimism*

Past Failure*

Loss of Pleasure*

Guilty Feelings*

Punishment Feelings*

Self-Dislike*

Self-Criticalness*

Suicidal Thoughts or Wishes*

Crying*

Agitation*

Loss of Interest*

Indecisiveness*

Worthlessness*

Loss of Energy*

Changes in Sleeping Pattern*

Irritability*

Changes in Appetite*

Concentration Difficulty*

Tiredness or Fatigue*

Loss of Interest in Sex*

Total Score