Mood and Sleep Questionnaire

Family Care Clinic | D. Blayne Laws, M.D. | Office 972-875-6700 | Fax 972-875-6790

Please correct the errors described below.

Depression Self-Rating Test

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

Office Use Only

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

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

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