Patient Name: <<Patient Demographics:Full Name>>	 

In the last 4 weeks:	None of the time	A little of the time	Some of the time	Most of the time	All of the time	Not stated / Missing	
1	about how often did you feel tired out for no good reason?	☐	☐	☐	☐	☐	☐	
2	about how often did you feel nervous?	☐	☐	☐	☐	☐	☐	
3	about how often did you feel so nervous that nothing could calm you down?	☐	☐	☐	☐	☐	☐	
4	about how often did you feel hopeless?	☐	☐	☐	☐	☐	☐	
5	about how often did you feel restless or fidgety?	☐	☐	☐	☐	☐	☐	
6	about how often did you feel so restless you could not sit still?	☐	☐	☐	☐	☐	☐	
7	about how often did you feel depressed?	☐	☐	☐	☐	☐	☐	
8	about how often did you feel that everything was an effort?	☐	☐	☐	☐	☐	☐	
9	about how often did you feel so sad that nothing could cheer you up?	☐	☐	☐	☐	☐	☐	
10	about how often did you feel worthless?	☐	☐	☐	☐	☐	☐	
TOTAL SCORE  	     	
11	how many days were you totally unable to work, study or manage your day to day activities because of these feelings?	      (Number of Days)	
12	aside from those days, in the past four weeks, how many days were you able to work or study or manage your day to day activities, but had to cut down on what you did because of these feelings?	      (Number of Days)	
13	how many times have you seen a doctor or any other health professional about these feelings?	      (Number of Consultations)	
14	how often have physical health problems been the main cause of these feelings?	☐	☐	☐	☐	☐	☐	

Date: <<Miscellaneous:Date>>