Name___________________________Age____________________________Sex (Circle one) M F

Instructions: Looking back over the last week, including today, help us understand how you have been feeling. Read each item carefully and mark the box under the category which best describes your current situation . For this questionnaire, work is defined as employment, school, housework, volunteer work and so forth. Almost

                                                                         Never Rarely Sometimes Frequently Always

1. I get along well with others                                  ___    ___        ___         ___         ___    2. I tire quickly                                                      ___    ___        ___         ___         ___

3. I feel no interest in things                                    ___    ___        ___         ___         ___

4. I feel stressed at work/school                               ___    ___        ___         ___         ___

5. I blame myself for things                                      ___    ___        ___         ___         ___

6. I feel irritated                                                    ___    ___        ___         ___         ___

7. I feel unhappy in my marriage/significant relationship ___    ___        ___         ___         ___

8. I have thoughts of ending my life                          ___    ___        ___         ___         ___ 

9. I feel weak                                                       ___    ___        ___         ___         ___

10. I feel fearful                                                    ___    ___        ___         ___         ___

11. After heaving drinking, I need a drink the next morning

to get going (If you do not drink, mark (never”)          ___    ___        ___         ___         ___

12. I find my work/school satisfying                          ___    ___        ___         ___         ___

13. I am a happy person                                         ___    ___        ___         ___         ___

14. I work/study too much                                      ___    ___        ___         ___         ___

15. I feel worthless                                                ___    ___        ___         ___         ___

16. I am concerned about family troubles                   ___    ___        ___         ___         ___

17. I have an unfulfilling sex life                                ___    ___        ___         ___         ___

18. I feel lonely                                                     ___    ___        ___         ___          ___ 

19. I have frequent arguments                                 ___    ___        ___         ___         ___

20. I feel loved and wanted                                     ___    ___        ___         ___         ___

21. I enjoy my spare time                                       ___    ___        ___         ___         ___

22. I have difficulty concentrating                            ___    ___        ___         ___         ___

23. I feel hopeless about the future                          ___    ___        ___         ___         ___

24. I like myself                                                     ___    ___        ___         ___         ___

25. Disturbing thoughts come into my mind that                                                                       I cannot get rid of                                                ___    ___        ___         ___         ___

26. I feel annoyed by people who criticize my drinking                                                            (or drug use) (If not applicable, mark (“never”)          ___    ___        ___         ___         ___

27. I have an upset stomach                                   ___    ___        ___         ___         ___

28. I am not working/studying as well as I used to       ___    ___        ___         ___         ___

29. My heart pounds too much                                 ___    ___         ___        ___         ___

30. I have trouble getting along with friends and                                                   
close acquaintances                                               ___    ___        ___         ___         ___

31. I am satisfied with my life                                   ___    ___        ___         ___         ___  

32. I have trouble at work/school because of                                                                  drinking or drug use (If not applicable, mark “never”)    ___    ___        ___         ___         ___

33. I feel that something bad is going to happen          ___    ___        ___         ___         ___

34. I have sore muscles                                           ___    ___        ___         ___         ___

35. I feel afraid of open spaces, of driving, or being                                                               on buses, subways and so forth                               ___    ___        ___         ___         ___

36. I feel nervous                                                   ___    ___        ___         ___         ___  

37. I feel my love relationships are full and complete     ___    ___        ___         ___         ___  

38. I feel that I am not doing well at work/school         ___    ___        ___         ___         ___

39. I have too many disagreements at work/school       ___    ___        ___         ___         ___

40. I feel something is wrong with my mind                  ___    ___        ___         ___         ___

41. I have trouble falling asleep or staying asleep         ___    ___        ___         ___         ___

42. I feel blue                                                        ___    ___        ___         ___         ___

43. I am satisfied with my relationships with others      ___    ___        ___         ___         ___

44. I feel angry enough at work/school to do                                                               something I might regret                                         ___    ___        ___         ___         ___

45. I have headaches                                             ___    ___        ___         ___         ___