Your initials please ^*

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Thank you, ___. Would you be willing to share your email with us? ^*

Just to send your results. We'll never spam your inbox!!

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What is your age? ^*

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Gender ^*

Male

Female

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Education ^*

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Marital Status ^*

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Depressed Mood ^*

sadness, hopeless, helpless, worthless

Absent

These feeling states indicated only on questioning

These feeling states spontaneously reported verbally

Communicates feeling states non-verbally, i.e. through facial expression, posture, voice and tendency to weep

Patient reports virtually only these feeling states in his/her spontaneous verbal and non-verbal communication

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Feelings of Guilt ^*

sadness, hopeless, helpless, worthless

Absent

Self reproach, feels he/she has let people down

Ideas of guilt or rumination over past errors or sinful deeds

Present illness is a punishment. Delusions of guilt

Hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations

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Suicide ^*

Absent

Feels life is not worth living

Wishes he/she were dead or any thoughts of possible death to self

Ideas or gestures of suicide

Attempts at suicide

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Insomnia : Early in the night ^*

No difficulty falling asleep

Complains of occasional difficulty falling asleep, i.e. more than 1⁄2 hour

Complains of nightly difficulty falling asleep

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Insomnia : Middle of the night ^*

No difficulty

Patient complains of being restless and disturbed during the night.

Waking during the night – any getting out of bed

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Insomnia - Early hours of the morning ^*

No difficulty

Waking in early hours of the morning but goes back to sleep

Unable to fall asleep again if he/she gets out of bed

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Work and Activities ^*

No difficulty

Thoughts and feelings of incapacity, fatigue or weakness related to activities, work or hobbies.

Loss of interest in activity, hobbies or work – either directly reported by the patient or indirect in listlessness, indecision and vacillation

Decrease in actual time spent in activities or decrease in productivity

Stopped working because of present illness

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Retardation ^*

slowness of thought and speech, impaired ability to concentrate, decreased motor activity

Normal speech and thought

Slight retardation during the interview

Obvious retardation during the interview

Interview difficult

Complete stupor

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Agitation ^*

None

Fidgetiness

Playing with hands, hair, etc

Moving about, can’t sit still

Hand wringing, nail biting, hair-pulling, biting of lips

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Anxiety Psychic ^*

No difficulty

Subjective tension and irritability

Worrying about minor matters

Apprehensive attitude apparent in face or speech

Fears expressed without questioning

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Anxiety Somatic ^*

Physiological concomitants of anxiety such as:
Gastro-intestinal – dry mouth, wind, indigestion, diarrhea, cramps, belching
Cardio-vascular – palpitations, headaches
Respiratory – hyperventilation, sighing urinary frequency sweating

Absent

Mild

Moderate

Severe

Incapacitating

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Somatic Symptoms Gastro-Intestinal ^*

None

Loss of appetite but eating without staff encouragement. Heavy feelings in abdomen

Difficulty eating without staff urging. Requests or requires laxatives or medication for bowels or medication for gastro-intestinal symptoms

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General Somatic Symptoms ^*

None

Heaviness in limbs, back or head. Backaches, headaches, muscle aches. Loss of energy and fatigability.

Any clear-cut symptom rates 2.

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Genital Symptoms ^*

symptoms such as loss of libido, menstrual disturbances

Absent

Mild

Severe

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Hypochondriasis ^*

Not present

Self-absorption (bodily)

Preoccupation with health

Frequent complaints, requests for help, etc

Hypochondriacal delusions

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Loss of weight ^*

No weight loss

Probable weight loss associated with present illness

Definite weight loss

Not assessed

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Insight ^*

Acknowledges being depressed and ill

Acknowledges illness but attributes cause to bad food, climate, overwork, virus, need for rest, etc

Denies being ill at all

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How do you feel after answering this questionnaire ^*

1 → Unsatisfied

10 → Satisfied

Unsatisfied Satisfied

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We are eager to hear more about how we can better support the community. Share what we're missing...

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