Name: _____________________________________________ Date: _____/_____/_____

There are 21 sets of statements on the front and back of this form. Please pick the one statement in each group that best describes the way you have felt for the last week, today included, and draw a circle around the number in front of that statement. If you cannot decide between more than one statement in a group, circle each answer that is correct for you.

0 I do not feel sad
1 I feel sad
2 I am sad all the time and I can't snap out of it
3 I am so sad or unhappy that I can't stand it

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0 I am not discouraged about the future
1 I feel discouraged about the future
2 I feel that I have nothing to look forward to
3 My future is hopeless and things cannot improve

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0 I do not feel like a failure
1 I feel that I have failed more than most people
2 As I look back, all I see is a lot of failures
3 I feel that I am a complete failure as a person

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0 I enjoy things as much as I used to
1 I don't enjoy things the way I used to
2 I don't get much pleasure out of anything
3 I am dissatisfied or bored with everything

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0 I don't feel especially guilty
1 I feel guilty some of the time
2 I feel guilty most of the time
3 I feel guilty all of the time

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0 I don't feel that I am being punished
1 I feel that I may be being punished
2 I expect to be punished
3 1 feel that I am now being punished

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0 I am not disappointed in myself
1 I am disappointed in myself
2 I am disgusted with myself
3 I hate myself

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0 I feel that I am no worse than anyone else
1 I am too critical of myself
2 I blame myself all the time for my faults
3 I blame myself for everything bad that happens

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0 I have no thoughts of killing myself
1 I have some thoughts of killing myself, but I know I will not carry them out
2 I would like to take my own life
3 I would kill myself I had the chance

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0 I don't cry any more than usual
1 I cry more than I used
2 I cry all the time now
3 I am so depressed now that I can't even cry

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0 I am no more irritated than usual
1 I get annoyed/irritated more easily than usual
2 I feel irritated all the time now
3 I am so down that things no longer even bother me

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0 1 have my usual interest in other people
1 I am less interested in others than usual
2 I now have little interest in other people
3 I have no interest at all in other people

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0 I make decisions now as well as I ever have
1 I now avoid making decisions if I can
2 It is harder for me to make decisions now than in the past
3 I just can't make decisions at all any more

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0 I sleep about as well as usual
1 I don’t sleep as well as usual
2 I wake up an hour or two early and can't go back to sleep
3 I awaken several hours early but cannot get back to sleep

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0 I have as much energy now as I usually do
1 I now tire more easily than usual
2 Almost everything tires me now
3 I am too tired to do much of anything

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0 I don't look any worse than usual
1 I fear that I now look old and unattractive
2 I feel that there are permanent changes in my appearance that make me look unattractive
3 I believe that I now look ugly

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0 I can work about as well as usual
1 It is hard for me to get started doing things now
2 I really have to push myself to get going
3 I can't do any work at all now

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0 My appetite is as good as usual
1 My appetite is not as good as it usually is
2 My appetite is much worse now
3 I now have no appetite at all

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0 I have lost little or no weight lately
1 I have lost more than 5 pounds
2 I have lost more than 10 pounds
3 I have lost more than 15 pounds

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I am trying to lose weight by eating less

circle: --Yes-----No--

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0 I am not more worried about my health than usual
1 I am more worried about my health than usual
2 I am so worried about my physical health that it is hard to think about much else
3 I am so worried about my physical problems that I cannot think of anything else

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0 My interest in sex is about what it usually is
1 I am less interested in sex than usual
2 I am much less interested in sex than usual
3 My interest in sex has recently dropped off completely

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Total _______________________________________

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BECK SCORING

0-19 INSIGNIFICANT

20-30 MILD

31-63 MODERATE TO SEVERE

FRED CREUTZMANN, M.D. – CARROLLTON

972-384-7277 or www.DrCmd.com