Instructions: Place a (√) check in the box to the right of each of the 15 symptom clusters to indicate how much this type of feeling has been bothering you in the past several days. Make sure you answer all the questions. If you feel unsure about any, put down your best guess. If you would like a weekly record of you progress, record your answers on the separate “Answer Sheet” instead of filling in the spaces to the right.
1. Sadness: Have you been feeling sad or down in the dumps?
2. Discouragement: Does the future look hopeless?
3. Low self-esteem: Do you feel worthless or think of yourself as a failure?
4. Inferiority: Do you feel inadequate or inferior to others?
5. Guilt: Do you get self-critical and blame yourself for everything?
6. Indecisiveness: Do you have trouble making up your mind about things?
7. Irritability and frustration: Have you been feeling resentful and angry often?
8. Loss of interest in life: Have you lost interest in your career, hobbies, family or things?
9. Loss of motivation: Do you feel overwhelmed and have to push yourself hard to do things?
10. Poor self-image: Do you think you’re looking old or unattractive?
11. Appetite changes: Have you lost your appetite? Or do you overeat or binge?
12. Sleep changes: Do you suffer from insomnia and find it hard to get a good night’s sleep? Or are you excessively tired and sleeping too much?
13. Loss of libido: Have you lost your interest in sex?
14. Hypochondriasis: Do you worry a great deal about your health?
15. Suicidal impulses: Do you have thoughts that life is not worth living or think that you might be better off dead?