A State of Illinois Licensed Psychological Association (License #098.000088)


Read over the statements grouped with each letter, A through U. Pick out the statement within each group that best describes the way you feel this week including today, that is, right at this moment. Highlight the number, or place an X before the statement that you have chosen in each group. If two or more statements in a group describe the way you feel equally well, circle each one. Be sure to read over all of the statements in each group before you decide on one. Total the number score from each group. If you marked more than one statement in a particular group, use the highest number circled in that group.

A.) Sadness
0 I do not feel sad.
1 I feel blue or sad.
2a I am blue or sad all the time and I can’t snap out of it.
2b I am so sad or unhappy that it is quite painful.
3 I am so sad or unhappy that I can’t stand it.

B.) Pessimism
0 I am not particularly pessimistic or discouraged about the future.
1 I feel discouraged about the future.
2a I feel I have nothing to look forward to.
2b I feel that I won’t ever get over my troubles.
3 I feel that the future is hopeless and that things cannot improve.

C.) Sense of failure
0 I do not feel like a failure.
1 I feel I have failed more than the average person.
2a I feel I have accomplished very little that is worthwhile or that
means anything.
2b As I look back on my life all I can see is a lot of failures.
3 I feel I am a complete failure as a person (parent, husband, wife).

D.) Dissatisfaction
0 I am not particularly dissatisfied.
1a I feel bored most of the time.
1b I don’t enjoy things the way I used to.
2 I don’t get satisfaction out of anything anymore.
3 I am dissatisfied with everything.

E.) Guilt
0 I don’t feel particularly guilty.
1 I feel bad or unworthy a good part of the time.
2a I feel quite guilty.
2b I feel bad or unworthy practically all the time now.
3 I feel as though I am very bad or worthless.

F.) Expectation or punishment
0 I don’t feel I am being punished.
1 I have a feeling that something bad may happen to me.
2 I feel I am being punished or will be punished.
3a I feel I deserve to be punished.
3b I want to be punished.

0 I don’t feel disappointed in myself.
1a I am disappointed in myself.
1b I don’t like myself.
2 I am disgusted with myself.
3 I hate myself.

H.) Self-accusations
0 I don’t feel I am any worse than anybody else.
1 I am critical of myself for my weaknesses or mistakes.
2 I blame myself for my faults.
3 I blame myself for everything bad that happens.

I.) Suicidal ideas
0 I don’t have any thoughts of harming myself.
1 I have thoughts of harming myself but I would not carry them out.
2a I feel I would be better off dead.
2b I feel my family would be better off if I were dead.
3a I have definite plans about committing suicide.
3b I would kill myself if I could.

J.) Crying
0 I don’t cry any more than usual.
1 I cry more now than I used to.
2 I cry all the time now. I can’t stop it.
3 I used to be able to cry but now I can’t cry at all even though I want to

K.) Irritability
0 I am no more irritated now than I ever am.
1 I get annoyed or irritated more easily than I used to.
2 I feel irritated all the time
3 I don’t get irritated at all at the things that used to irritate me.

L.) Social withdrawal
0 I have not lost interest in other people.
1 I am less interested in other people now than I used to be.
2 I have lost most of my interest in other people.
3 I have lost all my interest in other people and don’t care about them at all.

M.) Indecisiveness
0 I make decisions about as well as ever.
1 I try to put off making decisions.
2 I have great difficulty in making decisions.
3 I can’t make decisions at all anymore

N.) Body image change
0 I don’t feel I look any worse than I used to.
1 I am worried that I am looking old or unattractive.
2 I feel that there are permanent changes in my appearance and they make me
look unattractive.
3 I feel that I am ugly or repulsive-looking.

O.) Work retardation
0 I can work about as well as before.
1a It takes extra effort to get started at doing .
1b I don’t work as well as I used to.
2 I have to push myself very hard to do anything.
3 I can’t do any work at all.

P.) Insomnia
0 I can sleep as well as usual.
1 I wake up more tired in the morning than I used to.
2 I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.
3 I wake up early every day and can’t get more than 5 hours sleep.

Q.) Fatigability
0 I don’t get any more tired than usual.
1 I get tired more easily that I used to.
2 I get tired from doing anything.
3 I get too tired to do anything.

R.) Anorexia
0 My appetite is no worse than usual.
1 My appetite is not as good as it used to be.
2 My appetite is much worse now.
3 I have no appetite at all anymore.

S.) Weight loss
0 I haven’t lost much weight, if any, lately.
1 I have lost more than 5 pounds.
2 I have lost more than 10 pounds.
3 I have lost more than 15 pounds.

T.) Somatic preoccupation
0 I am no more concerned about my health than usual.
1 I am concerned about aches and pains or upset stomach or constipation.
2 I am so concerned with how I feel or what I feel that it’s hard to think of
much else.
3 I am completely absorbed in what I feel.

U.) Loss of libido
0 I have not noticed any recent change in my interest in sex.
1 I am less interested in sex that I used to be.
2 I am much less interested in sex now.
3 I have lost interest in sex completely.

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