| Sadness |
☐I am so sad or unhappy that I can't stand it. ☐I am blue or sad all the time and I can't snap out of it. ☐I feel sad or blue. ☐I do not feel sad. |
| Pessimism |
☐I feel that the future is hopeless and that things cannot improve. ☐I feel I have nothing to look forward to. ☐I feel discouraged about the future. ☐I am not particularly pessimistic or discouraged about the future. |
| Sense of failure |
☐I feel I am a complete failure as a person (parent, husband, wife). ☐As I look back on my life, all I can see is a lot of failures. ☐I feel I have failed more than the average person. ☐I do not feel like a failure. |
| Dissatisfaction |
☐I am dissatisfied with everything. ☐I don't get satisfaction out of anything anymore. ☐I don't enjoy things the way I used to. ☐I am not particularly dissatisfied. |
| Guilt |
☐I feel as though I am very bad or worthless. ☐I feel quite guilty. ☐I feel bad or unworthy a good part of the time. ☐I don't feel particularly guilty. |
| Self-dislike |
☐I hate myself. ☐I am disgusted with myself. ☐I am disappointed in myself. ☐I don't feel disappointed in myself. |
| Self-harm |
☐I would kill myself if I had the chance. ☐I have definite plans about committing suicide. ☐I feel I would be better off dead. ☐I don't have any thoughts of harming myself. |
| Social withdrawal |
☐I have lost all of my interest in other people and don't care about them at all. ☐I have lost most of my interest in other people and have little feeling for them. ☐I am less interested in other people than I used to be. ☐I have not lost interest in other people. |
| Indecisiveness |
☐I can't make any decisions at all anymore. ☐I have great difficulty in making decisions. ☐I try to put off making decisions. ☐I make decisions about as well as ever. |
| Self-image change |
☐I feel that I am ugly or repulsive-looking. ☐I feel that there are permanent changes in my appearance and they make me look unattractive. ☐I am worried that I am looking old or unattractive. ☐I don't feel that I look any worse than I used to. |
| Work difficulty |
☐I can't do any work at all. ☐I have to push myself very hard to do anything. ☐It takes extra effort to get started at doing something. ☐I can work about as well as before. |
| Fatigability |
☐I get too tired to do anything. ☐I get tired from doing anything. ☐I get tired more easily than I used to. ☐I don't get any more tired than usual. |
| Anorexia |
☐I have no appetite at all anymore. ☐My appetite is much worse now. ☐My appetite is not as good as it used to be. ☐My appetite is no worse than usual. |
