| Questions | Responses and scores |
| |
| 1) Do you ever feel like crying, or do you cry? | 1 No | 2 Sometimes | 3 Almost all the time |
| 2) Do you always feel miserable and unhappy? | 1 No | 2 Sometimes | 3 Almost all the tome |
| 3) Do you always feel nervous and irritated? | 1 No | 2 Sometimes | 3 Almost all the time |
| 4) Do you feel annoyed and aggravated over small things? | 1 No | 2 Sometimes | 3 Almost all the time |
| 5) Do you have a normal appetite? | 3 No | 2 I sometimes lose my appetite | 1 Yes |
| 6) Are you in your best mood in the morning? | 3 No | 2 Sometimes | 1 Almost all the time |
| 7) Do you get somewhat tired? | 1 No | 2 Sometimes | 3 Almost all the time |
| 8) Are you able to put your usual effort into your work? | 3 No | 2 I sometimes can’t | 1 Yes |
| 9) Do you feel satisfied with the sleep you are getting? | 3 No | 2 I sometimes don’t feel satisfied | 1 Yes |
| 10) Do you have trouble falling asleep for any reason other than pain? | 1 No | 2 Sometimes | 3 Almost all the time |