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Basic Symptom Screening
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Name
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Over the last two weeks, how often have you been bothered by TROUBLE RELAXING?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
Date
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Over the last two weeks, how often have you been bothered by FEELING ANXIOUS, NERVOUS, or ON EDGE?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
Over the last two weeks, how often have you been bothered by NOT BEING ABLE TO STOP OR CONTROL WORRYING?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
Over the last two weeks, how often have you been bothered by WORRYING TOO MUCH ABOUT DIFFERENT THINGS?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
Over the last two weeks, how often have you been bothered by BECOMING EASILY ANNOYED OR IRRITABLE?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
Over the last two weeks, how often have you been bothered by BEING SO RESTLESS THAT IT IS HARD TO SIT STILL?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
Over the last two weeks, how often have you been bothered by FEELING AFRAID, AS IF SOMETHING AWFUL MIGHT HAPPEN?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
Over the last two weeks, how often have you been bothered by LITTLE INTEREST OR PLEASURE IN DOING THINGS?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
Over the last two weeks, how often have you been bothered by FEELING DOWN, DEPRESSED, OR HOPELESS?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
Over the last two weeks, how often have you been bothered by TROUBLE FALLING OR STAYING ASLEEP, OR SLEEPING TOO MUCH?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
Over the last two weeks, how often have you been bothered by FEELING TIRED OR HAVING LITTLE ENERGY?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
Over the last two weeks, how often have you been bothered by POOR APPETITE OR OVEREATING?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
Over the last two weeks, how often have you been bothered by FEELING BAD ABOUT YOURSELF - THAT YOU ARE A FAILURE OR HAVE LET OTHERS DOWN?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
Over the last two weeks, how often have you been bothered by TROUBLE CONCENTRATING ON THINGS, SUCH AS READING THE NEWSPAPER OR WATCHING TELEVISION?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
Over the last two weeks, how often have you been bothered by THOUGHTS THAT YOU WOULD BE BETTER OFF DEAD, OR OF HURTING YOURSELF?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
Over the last two weeks, how often have you been bothered by MOVING OR SPEAKING SO SLOWLY THAT OTHER PEOPLE COULD HAVE NOTICED - OR THE OPPOSITE, BEING SO FIDGETY OR RESTLESS THAT YOU ARE MOVING AROUND A LOT MORE THAN USUAL?
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Not At All
Several Days
More Than Half The Days
Nearly Every Day
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
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Not Difficult At All
Somewhat Difficult
Very Difficult
Extremely Difficult
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