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Name

Phone No.

Mood

 
 
 
 

Outlook on the Future

 
 
 
 

Feelings of Failure

 
 
 
 

Ability to Enjoy

 
 
 
 

Feelings of Guilt

 
 
 
 

Feelings of Punishment

 
 
 
 

Self-Hate

 
 
 
 

Self-Criticism

 
 
 
 

Suicidal Thoughts

 
 
 
 

Crying

 
 
 
 

Irritability

 
 
 
 

Social Interest

 
 
 
 

Decision-Making Ability

 
 
 
 

Feelings About Appearance

 
 
 
 

Interest in Work

 
 
 
 

Fatigue

 
 
 
 

Appetite

 
 
 
 

Weight Loss

 
 
 
 

Health Concerns

 
 
 
 

Sexual Desire

 
 
 
 

General Functioning

 
 
 
 

Irritability

 
 
 
 

Question 1 of 24