Please circle the number for each statement which best describes how often you felt or behaved

this
way DURING THE PAST WEEK.
Rarely or
none of the
time (less
than 1 day)

Some or a
little of the
time (1-2
days)

Occasionally or a
moderate
amount of the
time (3-4 days)

Most or all
of the time
(5-7 days)

1) I was bothered by things that

usually dont bother me

2) I had trouble keeping my

mind on what I was doing

3) I felt depressed

4) I felt that everything I did was

an effort

5) I felt hopeful about the future

6) I felt fearful

7) My sleep was restless

8) I was happy

9) I felt lonely

10) I could not get going

11) I felt nervous, anxious, or on

edge

12) I was not able to stop or

control worrying

13) I worried too much about

different things

14) I had trouble relaxing

15) I was so restless it was hard

to sit still

16) I became easily annoyed or

irritable

17) I felt afraid as if something

awful might happen

18) I felt relaxed

During the past week:

Rarely or
none of the
time (less
than 1 day)

Some or a
little of the
time (1-2
days)

Occasionally or a
moderate
amount of the
time (3-4 days)

Most or all
of the time
(5-7 days)

19) I felt overwhelmed

20) I felt that I was losing control

of my life

21) I felt that I was near a

breaking point

22) I felt so stressed that I

wanted to hit something

23) I felt that I just couldnt keep

up with everything

24) It was very easy for me to

fall asleep at night

25) I was disorganized

26) It was hard for me to keep

track of several things at once

27) Things distracted me from

what I was doing

28) I had trouble getting started

on tasks

29) I was absent-minded

30) I could not keep my mind on

things unless they were really
interesting

31) I felt irritated by other

people

32) I lost my temper

33) I was patient and forgiving

34) I felt angry

35) I felt resentful

36) I felt annoyed

37) I felt kind toward people

During the past week: