Mood Questionnaire Name * First Name Last Name Over the last 2 weeks, how often have you been bothered by any of the following problems? Question 1 (required) Little interest or pleasure in doing things Not at all Several days More than half the days Nearly every day Question 2 * Feeling down, depressed, or hopeless Not at all Several days More than half the days Nearly every day Question 3 * Trouble falling or staying asleep or sleeping too much Not at all Several days More than half the days Nearly every day Question 4 * Feeling tired or having little energy Not at all Several days More than half the days Nearly every day Question 5 * Poor appetite or overeating Not at all Several days More than half the days Nearly every day Question 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 Question 7 * Trouble concentrating on things- reading the newspaper or watching TV Not al all Several days More than half the days Nearly every day Question 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 Question 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 Question 10 * Feeling nervous, anxious or on edge Not at all Several days More than half the days Nearly every day Question 11 * Not being able to stop or control worry Not at all Several days More than half the days Nearly every day Question 12 * Worrying too much about different things Not at all Several days More than half the days Nearly every day Question 13 * Trouble relaxing Not at all Several days More than half the days Nearly every day Question 14 * Being so restless that it is hard to sit still Not at all Several days More than half the days Nearly every day Question 15 * Becoming easily annoyed or irritable Not at all Several days More than half the days Nearly every day Question 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.
