Mood and Sleep Questionnaire

Patient Name:

DOB

Depression Self-Rating Test

Instructions: Please select the one response to each item that best describes you for the past seven days.

Enter the highest score for items 1-4

Enter the highest score for items 6-9

Enter the highest score for items 15 or 16

Office Use Only

1-4

6-9

15-16

Total

Anxiety Screener

Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by selecting the number in the corresponding dropdown next to each symptom

Scoring - Sum each column. Then sum the column totals to achieve a grand score. Write that score here

Epworth Sleepiness Scale

The following questionnaire will help you measure your general level of daytime sleepiness. You are to rate the chance that you would doze off or fall asleep during different routine daytime situations.

Answers to the questions are rated on a reliable scale called the Epworth Sleepiness Scale (ESS). Each item is rated from 0 to 3, with 0 meaning you would never doze or fall asleep in a given situation, and 3 meaning that there is a very high chance that you would doze or fall asleep in that situation.

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? Even if you haven't done some of these activities recently, think about how they would have affected you.

Use this scale to choose the most appropriate number for each situation:

0= would never doze, 1 = slight chance of dozing, 2 = moderate chance of dozing, 3 = high chance of dozing

It is important that you select a number (0 to 3) on each of the questions

Sitting and reading