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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