15

Have you lost interest in things

1/Yes

2/No

16

Do you feel that you are a worthless person

1/Yes

2/No

17

Do you feel tired all the time

1/Yes

2/No

18

Do you have uncomfortable feelings in your stomach

1/Yes

2/No

19

Are you easily tired

1/Yes

2/No

20

Has any thoughts of hurting yourself been in your mind

1/Yes

2/No

21

If you ever had thoughts of hurting your self, please explain these thoughts