1 |
Do you often have headaches? |
Yes |
No |
2 |
Is your appetite poor? |
Yes |
No |
3 |
Do you sleep badly? |
Yes |
No |
4 |
Are you easily frightened? |
Yes |
No |
5 |
Do your hands shake? |
Yes |
No |
6 |
Do you feel nervous, tense or worried? |
Yes |
No |
7 |
Is your digestion poor? |
Yes |
No |
8 |
Do you have trouble thinking clearly? |
Yes |
No |
9 |
Do you feel unhappy? |
Yes |
No |
10 |
Do you cry more than usual? |
Yes |
No |
11 |
Do you find it difficult to enjoy your daily activities? |
Yes |
No |
12 |
Do you find it difficult to make decisions? |
Yes |
No |
13 |
Is your daily work suffering? |
Yes |
No |
14 |
Are you unable to play a useful part in life? |
Yes |
No |
15 |
Have you lost interest in things? |
Yes |
No |
16 |
Do you feel that you are a worthless person? |
Yes |
No |
17 |
Has the thought of ending your life been on your mind? |
Yes |
No |
18 |
Do you feel tired all the time? |
Yes |
No |
19 |
Do you have uncomfortable feelings in your stomach? |
Yes |
No |
20 |
Are you tired easily? |
Yes |
No |
|
Total number of yes answers |
|