Checklist Adult

Name

Age

Date

Please answer all the following questions, within the last 2 weeks how often have the following happened:

Please use the following scale to answer: 0 (none, not at all) 1 (slight, rare less than a day or 2) 2 (mild, several days)3 (moderate, more than half the days) 4 (severe, nearly every day)

Severity Measure for Depression: Scale 0 (Not at all) 1 (Several days) 2 (More than half the days) or 3 (Nearly every day)

Please complete the following questions for symptoms within the past 7 days

Little interest or pleasure in doing things

0 1 2 3

Feeling down, depressed, or hopeless

0 1 2 3

Trouble falling or staying asleep, or sleeping too much

0 1 2 3

Feeling tired or having little energy

0 1 2 3

Poor appetite or overeating

0 1 2 3

Feeling bad about yourself—or that you are a failure or have let yourself or your family down

0 1 2 3

Trouble concentrating on things, such as reading the newspaper or watching television

0 1 2 3

Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual

0 1 2 3

Thoughts that you would be better off dead or of hurting yourself in some way

0 1 2 3

Severity Measure for Anxiety: 0 (Never) 1 (Occasionally) 2 (Half the time) 3 (Most the time) 4 (All the time)

Please complete the following questions for symptoms within the past 7 days

Felt moments of sudden terror, fear, or fright

0 1 2 3 4

Felt anxious, worried, or nervous

0 1 2 3 4

Had thoughts of bad things happening, such as family tragedy, ill health, loss of a job, or accidents

0 1 2 3 4

Felt a racing heart, sweaty, trouble breathing, faint, or shaky

0 1 2 3 4

Felt tense muscles, felt on edge or restless, or had trouble relaxing or trouble sleeping

0 1 2 3 4

Avoided, or did not approach or enter, situations about which I worry

0 1 2 3 4

Left situations early or participated only minimally due to worries

0 1 2 3 4

Spent lots of time making decisions, putting off making decisions, or preparing for situations, due to worries

0 1 2 3 4

Sought reassurance from others due to worries

0 1 2 3 4

Needed help to cope with anxiety (e.g., alcohol or medication, superstitious objects, or other people)

0 1 2 3 4

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