QIDS

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QIDS

Your birthdate helps us identify your data accurately.

Birthday *

YYYY

Your First Name *

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Client

Parent

CHECK THE ONE RESPONSE TO EACH ITEM THAT BEST DESCRIBES YOU FOR THE PAST SEVEN DAYS.

During the past 7 days...

Falling asleep *

1- I never take longer than 30 minutes to fall asleep.

2- I take at least 30 minutes to fall asleep, less than half of the time.

3- I take at least 30 minutes to fall asleep, more than half of the time.

4- I take more than 60 minutes to fall asleep, more than half of the time.

Sleep during the night *

1- I do not wake up at night.

2- I wake up at least once a night, but I go back to sleep easily.

3- I have a restless, light sleep with a few brief awakenings each night.

4- I awaken more than once a night and stay awake for 20 minutes or more, more than half the time.

Waking up too early *

1- Most of the time, I awaken no more than 30 minutes before I need to get up.

2- More than half the time, I awaken more than 30 minutes before I need to get up.

3- I almost always awaken at least one hour or so before I need to, but I go back to sleep eventually.

4- I awaken at least one hour before I need to, and can't go back to sleep.

Sleeping too much *

1- I sleep no longer than 7-8 hours/night, without napping during the day.

2- I sleep no longer than 10 hours in a 24-hour period including naps.

3- I sleep no longer than 12 hours in a 24-hour period including naps.

4- I sleep longer than 12 hours in a 24-hour period including naps.

Feeling Sad *

1- I do not feel sad.

2- I feel sad, less than half of the time.

3- I feel sad, more than half of the time.

4- I feel sad nearly all of the time.

Decreased appetite *

1 - There is no change from my usual appetite.

2 - I eat somewhat less often or lesser amounts of food than usual.

3 - I eat much less than usual and only with personal effort.

4 - I rarely eat within a 24-hour period, and only with extreme personal effort or when others persuade me to eat.

Increased appetite *

1 - There is no change from my usual appetite.

2 - I feel a need to eat more frequently than usual.

3 - I regularly eat more often and/or greater amounts of food than usual.

4 - I feel driven to overeat both at mealtime and between meals.

(Within the last 2 weeks) Decreased weight

1 - I have not had a change in weight.

2 - I feel as if I have had a slight weight loss.

3 - I have lost 2 pounds or more.

4 - I have lost 5 pounds or more.

Clear selection

(Within the last 2 weeks) Increased weight

1 - I have not had a change in weight.

2 - I feel as if I have had a slight weight gain

3 - I have gained 2 pounds or more

4 - I have gained 5 pounds or more

Clear selection

In the past 7 days...

Concentration/Decision making *

1- There is no change in my usual capacity to concentrate or make decisions.

2- I occasionally feel indecisive or find that my attention wanders.

3- Most of the time, I struggle to focus my attention or to make decisions.

4- I cannot concentrate well enough to read or cannot make even minor decisions.

View of Myself *

1- I see myself as equally worthwhile and deserving as other people.

2- I am more self-blaming than usual.

3- I largely believe that I cause problems for others.

4- I think almost constantly about major and minor defects in myself.

Thoughts of Death or Suicide *

1- I do not think of suicide or death.

2- I feel that life is empty or wonder if it's worth living.

3- I think of suicide or death several times a week for several minutes.

4- I think of suicide or death several times a day in some detail, or I have made specific plans for suicide or have actually tried to take my life.

General Interest *

1- There is no change from usual in how interested I am in other people or activities.

2- I notice that I am less interested in people or activities.

3- I find I have interest in only one or two of my formerly pursued activities.

4- I have virtually no interest in formerly pursued activities.

Energy Level *

1- There is no change in my usual level of energy.

2- I get tired more easily than usual.

3- I have to make a big effort to start or finish my usual daily activities (for example, shopping, homework, cooking, or going to work).

4- I really cannot carry out most of my usual daily activities because I just don't have the energy.

Feeling Slowed Down *

1- I think, speak, and move at my usual rate of speed.

2- I find that my thinking is slowed down or my voice sounds dull or flat.

3- It takes me several seconds to respond to most questions and I'm sure my thinking is slowed.

4- I am often unable to respond to questions without extreme effort.

Feeling Restless *

1- I do not feel restless.

2- I'm often fidgety, wringing my hands, or need to shift how I am sitting.

3- I have impulses to move about and am quite restless.

4- At times, I am unable to stay seated and need to pace around.

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