Name:
Date:
/
Month
/
Day
Year
Date
Over the last two weeks, how often have you been bothered by any of the following problems?
Rows
Not at all
0
Several days
1
More than half the days
2
Nearly every day
3
Score
1.Little interest or pleasure in doing things
2.Feeling down, depressed, or hopeless
3.Trouble falling or staying asleep, or sleeping too much
4.Feeling tired or having little energy
5.Poor appetite or overeating
6.Feeling bad about yourself or that you are a failure or have let yourself or your family down
7.Trouble concentrating on things, such as reading the newspaper or watching television
8.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
9.Thoughts that you would be better off dead or of hurting yourself in some way
Total Score
10. How often did you have a drink containing alcohol in the past year?
Never (skip the last two questions)
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
11. How many drinks containing alcohol did you have on a typical day when you are drinking in the past year?
1-2
3-4
5-6
7-9
>10
12. How often did you have 6 or more drinks on one occasion in the past year?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
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