| Item | Never | Sometimes | Often | Always | |
| 1 | Able to concentrate | ||||
| 2 | Lost much sleep | ||||
| 3 | Playing useful part | ||||
| 4 | Capable of making decisions | ||||
| 5 | Under stress | ||||
| 6 | Could not overcome difficulties | ||||
| 7 | Enjoy normal activities | ||||
| 8 | Face up to problems | ||||
| 9 | Feeling unhappy or depressed | ||||
| 10 | Losing confidence | ||||
| 11 | Thinking of self as worthless | ||||
| 12 | Feeling reasonably happy |