| (Circle the appropriate number for each item) | A None |
B Questionable |
C Mild |
D Definite |
| 1. Feeling burdened, empty, down, sad, hopeless? | 0 | 1 | 2 | 3 |
| 2. General lack of interest or pleasure, don't care? | 0 | 1 | 2 | 3 |
| 3. Change of appetite, weight gain or loss? | 0 | 1 | 2 | 3 |
| 4. Change in sleeping habits, difficulty sleeping? | 0 | 1 | 2 | 3 |
| 5. Feeling irritable, frustrated, angry, emotionally fragile? | 0 | 1 | 2 | 3 |
| 6. Feeling fatigued, loss of energy, slowed speech or movement? | 0 | 1 | 2 | 3 |
| 7. Feelings of worthlessness, inappropriate guilt, or failure? | 0 | 1 | 2 | 3 |
| 8. Decrease in clear thinking, concentration, decision-making? | 0 | 1 | 2 | 3 |
| 9. Thoughts of death, not worth living, harming yourself or others? | 0 | 1 | 2 | 3 |
| Sub totals |
| 0 - 6 . . . . . . . . . . | None | Please Note: Having recently faced a dramatic emotional crisis or loss can cause situational depression or bereavement. |
| 7 - 10 . . . . . . . . . | Mild | |
| 11 - 19 . . . . . . . . | Moderate | |
| 20 or above . . . . . | Severe |