Mood Questionnaire Name * First Name Last Name Over the last 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things Not at all Several days More than half the days Nearly every day 2. Feeling down, depressed, or hopeless * Not at all Several days More than half the days Nearly every day 3. Trouble falling or staying asleep or sleeping too much * Not at all Several days More than half the days Nearly every day 4. Feeling tired or having little energy * Not at all Several days More than half the days Nearly every day 5. Poor appetite or overeating * Not at all Several days More than half the days Nearly every day 6. Feeling bad about yourself or that you’re a failure or have let yourself or your family down * Not at all Several days More than half the days Nearly every day 7. Trouble concentrating on things- reading the newspaper or watching TV * Not al all Several days More than half the days Nearly every day 8. Moving/speaking slowly so other people could have noticed or being so fidgety/restless you have been moving around a lot more than usual * Not at all Several days More than half the days Nearly every day 9. Thoughts that you would be better off dead, or hurting yourself in some way * Not at all Several days More than half the days Nearly every day 10. Feeling nervous, anxious or on edge * Not at all Several days More than half the days Nearly every day 11. Not being able to stop or control worry * Not at all Several days More than half the days Nearly every day 12. Not being able to stop or control worry * Not at all Several days More than half the days Nearly every day 13. Trouble relaxing * Not at all Several days More than half the days Nearly every day 14. Being so restless that it is hard to sit still * Not at all Several days More than half the days Nearly every day 15. Becoming easily annoyed or irritable * Not at all Several days More than half the days Nearly every day 16. Feeling afraid as if something awful might happen * Not at all Several days More than half the days Nearly every day Thank you. Your responses have been submitted to your therapist. Mood Questionnaire Name * First Name Last Name Over the last 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things Not at all Several days More than half the days Nearly every day 2. Feeling down, depressed, or hopeless * Not at all Several days More than half the days Nearly every day 3. Trouble falling or staying asleep or sleeping too much * Not at all Several days More than half the days Nearly every day 4. Feeling tired or having little energy * Not at all Several days More than half the days Nearly every day 5. Poor appetite or overeating * Not at all Several days More than half the days Nearly every day 6. Feeling bad about yourself or that you’re a failure or have let yourself or your family down * Not at all Several days More than half the days Nearly every day 7. Trouble concentrating on things- reading the newspaper or watching TV * Not al all Several days More than half the days Nearly every day 8. Moving/speaking slowly so other people could have noticed or being so fidgety/restless you have been moving around a lot more than usual * Not at all Several days More than half the days Nearly every day 9. Thoughts that you would be better off dead, or hurting yourself in some way * Not at all Several days More than half the days Nearly every day 10. Feeling nervous, anxious or on edge * Not at all Several days More than half the days Nearly every day 11. Not being able to stop or control worry * Not at all Several days More than half the days Nearly every day 12. Not being able to stop or control worry * Not at all Several days More than half the days Nearly every day 13. Trouble relaxing * Not at all Several days More than half the days Nearly every day 14. Being so restless that it is hard to sit still * Not at all Several days More than half the days Nearly every day 15. Becoming easily annoyed or irritable * Not at all Several days More than half the days Nearly every day 16. Feeling afraid as if something awful might happen * Not at all Several days More than half the days Nearly every day Thank you. Your responses have been submitted to your therapist.
