Please read each statement and record a number 0, 1, 2 or 3 which indicated how much the statement applied to you over the past two weeks. There are no right or wrong answers. Do not spend too much time on any one statement. This assessment is not intended to be a diagnosis. If you are concerned about your results in any way, please speak with a qualified professional.

0 = Not at all

1 = Several days

2 = More than half the days

3 = Nearly every day

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Message Sent.

Privacy - please note - this form neither saves nor transmits any information about you or your assessment scores. If you wish to keep your results you will need to print this document. These results are intended as a guide to your health and are presented for educational purposes only. They are not intended to be a clinical diagnosis. If you are concerned in any way about your health, please consult with a qualified health professional.