Self Evaluation Template

Name*

First NameLast Name

Please select your last evaluation date.*

01. I feel overwhelmingly sad at times*

	0	1	2	3

0 is Disagree, 3 is Agree

02. When I think of the future I feel hopeless*

	0	1	2	3

0 is Disagree, 3 is Agree

03. I feel like a complete failure*

	0	1	2	3

0 is Disagree, 3 is Agree

04. I get a lot of satisfaction / joy from doing things*

	0	1	2	3

0 is Disagree, 3 is Agree

05. I feel guilty about something most of the time*

	0	1	2	3

0 is Disagree, 3 is Agree

06. I feel like I am being punished*

	0	1	2	3

0 is Disagree, 3 is Agree

07. I feel disappointed (even disgusted) with myself*

	0	1	2	3

0 is Disagree, 3 is Agree

08. The bad things in my life aren’t all my fault*

	0	1	2	3

0 is Disagree, 3 is Agree

09. I am often on the brink of tears or cry*

	0	1	2	3

0 is Disagree, 3 is Agree

10. I feel irritated and annoyed by things in my life*

	0	1	2	3

0 is Disagree, 3 is Agree

11. I am very interested in other people’s lives and like to listen to them*

	0	1	2	3

0 is Disagree, 3 is Agree

12. I find it easy to make decisions, big and small*

	0	1	2	3

0 is Disagree, 3 is Agree

13. I think I am unattractive or ugly*

	0	1	2	3

0 is Disagree, 3 is Agree

14. I find it really hard to do anything, especially work*

	0	1	2	3

0 is Disagree, 3 is Agree

15. My sleep patterns have been really disrupted*

	0	1	2	3

0 is Disagree, 3 is Agree

16. I am so tired I don’t have the energy to do anything*

	0	1	2	3

0 is Disagree, 3 is Agree

17. My appetite has changed a lot*

	0	1	2	3

0 is Disagree, 3 is Agree

18. I have lost a lot of weight*

	0	1	2	3

0 is Disagree, 3 is Agree

19. I am very concerned, even preoccupied, with my physical health*

	0	1	2	3

0 is Disagree, 3 is Agree

20. I am not interested in sexual relations at all*

	0	1	2	3

0 is Disagree, 3 is Agree

21. I have thought about ending my life*

	0	1	2	3

0 is Disagree, 3 is Agree

Calculation

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