• Format: (000) 000-0000.

  • How did you feel over the past week?

    CES-D
  • I was bothered by things that usually don't bother me*
  • I did not feel like eating; my appetite was poor*
  • I felt that I could not shake off the blues even with help from my family or friends.*
  • I felt I was just as good as other people*
  • I had trouble keeping my mind on what I was doing*
  • I felt depressed*
  • I felt that everything I did was an effort*
  • I felt hopeful about the future*
  • Have you wished you were dead or wished you could go to sleep and not wake up?*
  • Have you actually had any thoughts of killing yourself?*
  • Have you been thinking about how you might do this?*
  • Have you had these thoughts and had some intention of acting on them?*
  • Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?*
  • I thought my life had been a failure*
  • I felt fearful*
  • My sleep was restless*
  • I was happy*
  • I talked less than usual*
  • I felt lonely*
  • People were unfriendly*
  • I enjoyed life*
  • I had crying spells*
  • I felt sad*
  • I felt that people dislike me*
  • I could not get going*
  • I found it hard to focus on anything other than my anxiety*
  • My worries overwhelmed me*
  • I felt uneasy*
  • In the last 2 weeks I have had difficulty falling asleep*
  • Difficulty staying asleep*
  • Problems waking up too early*
  • How satisfied/dissatisfied are you with your current sleep pattern?*
  • How noticeable to others do you think your sleep problem is in terms of impairing the quality of your life?*
  • How worried/distressed are you about your current sleep problem?*
  • In the past week, I missed my medications*
  • To what extent do you consider your sleep problem to interfere with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc) currently?*
  • Medication side effects bother me*
  • Should be Empty: