INSTRUCTIONS: This questionnaire will help your physician know how you are feeling. Read every sentence. Place an “X” on the answer that best describes how you have been feeling during the LAST WEEK. You do not have to think too much to answer. In this questionnaire, spontaneous answers are more important. Mark only one answer for each question.

A1. I feel tense or wound up:

D1. I still enjoy the things I used to:

A2. I get a sort of frightened feeling as if something awful is about to happen:

D2. I can laugh and see the funny side of things:

A3. Worrying thoughts go through my mind:

D3. I feel cheerful:

A4. I can seat at ease and feel relaxed:

D4. I feel as I am slowed down:

A5. I get a sort of frightened feeling like butterflies in the stomach:

D5. I have lost interest in my appearance:

A6. I feel restless, as if I had to be on the move:

D6. I look forward with enjoyment to things:

A7. I get a sudden feeling of panic:

D7. I can enjoy a good TV or radio program or book: