Improving Well-Being Program - Amputee Coalition

How Are You Feeling?

Indicate your agreement with each item below by checking the appropriate box. Please be open and honest in your responses.

	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things.	Not at all	Several days	More than half the days	Nearly every day
Feeling down, depressed or hopeless.	Not at all	Several days	More than half the days	Nearly every day
Trouble falling or staying asleep, or sleeping too much.	Not at all	Several days	More than half the days	Nearly every day
Feeling tired or having little energy.	Not at all	Several days	More than half the days	Nearly every day
Poor appetite or overeating.	Not at all	Several days	More than half the days	Nearly every day
Feeling bad about yourself, or that you are a failure, or have let yourself, or your family down.	Not at all	Several days	More than half the days	Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television.	Not at all	Several days	More than half the days	Nearly every day
Moving or speaking so slowly that other people could have noticed. Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual.	Not at all	Several days	More than half the days	Nearly every day
Thoughts that you would be better off dead, or of hurting yourself in some way.	Not at all	Several days	More than half the days	Nearly every day