Indicate how strongly you agree or disagree with the following:

I often have a desire to escape.

I have a sense of inner emptiness.

I am indecisive.

I have erratic or incongruent emotions.

I often have a “don’t care” attitude.

I don’t feel like I have any control over my life.

I don’t have much motivation to be with people.

My interest in friendship, food, entertainment is low.

I feel emotionally exhausted.

I feel depressed.

I rarely have a good day.

I am chronically tired and may even wake up exhausted.

I have symptoms such as heart palpitations, recurrent or lingering sickness, chest pains, or aching.

I feel “wiped out” a lot.

I feel “run down”.

I feel trapped.

I feel hopeless.

I feel worthless.

I feel anxious most of the time.

What used to be a little thing sets me off and I tend to overreact.

Answers: 1) strongly disagree, 2) disagree, 3) moderate, 4) agree, 5) strongly agree