Name:

Date:

Make check mark (√) n appropriate column

A little

of the time

Some

of the time

Good part

of the time

Most

of the time

1. I feel down-hearted and blue

2. Morning is when I feel the best

3. I have crying spells or feel like it

4. I have trouble sleeping at night

5. I eat as much as I used to

6. I still enjoy sex

7. I notice that l am losing weight

8. I have trouble with constipation

9. My heart beats faster than usual

10. I get tired for no reason

11. My mind is as dear as it used to be

12. I find it easy to do the things l used to

13. I am restless and can’t keep still

14. I feel hopeful about the future

15. I am more irritable than usual

16. I find it easy to make decisions

17. I feel that I am useful and needed

18. My life is pretty full

19. I feel that others would be better off if l were dead

20. I still enjoy the things to do