This form is not a diagnostic instrument and is only to be used within the context of your medical treatment and by you if you are greater than 18 years old. Share your checklist responses and assessment with your physician or other health care provider. The maker and provider of this form disclaims any liability, loss, or risk incurred as a consequence, directly or indirectly, from the use and application of any of this material.

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Over the last two weeks or more, have you noticed the following:

(for each line click the circle that best applies to you)   Not at all   Rarely   Sometimes   Often   Most of the Time
1 .
I feel sad, down in the dumps or unhappy
         
2 .
I can’t concentrate or focus
         
3 .
Nothing seems to give me much pleasure
         
4 .
I feel tired; have no energy
         
5 .
I have had thoughts of suicide
         
6 .
Changes in sleeping patterns:
         
a. I have difficulty sleeping
         
b. I have been sleeping too much
         
7 .
Changes in appetite:
         
a. I have lost some appetite
         
b. I have been eating more
         
8 .
I feel tense, anxious or can’t sit still
         
9 .
I feel worried or fearful
         
10 .
I have attacks of anxiety or panic
         
11 .
I worry about dying or losing control
         
12 .
I am nervous or shaky in social situations
         
13 .
I have nightmares or flashbacks
         
14 .
I am jumpy or feel startled easily
         
15 .
I avoid places that strongly remind me of a bad experience
         
16 .
I feel dull, numb, or detached
         
17 .
I can’t get certain thoughts out of my mind
         
18 .
I feel I must repeat certain acts or rituals
         
19 .
I feel the need to check and recheck things
         

At any time in your life have you:

20 .
Had more energy than usual
         
21 .
Felt unusually irritable or angry
         
22 .
Felt unusually excited, revved up or high
         
23 .
Needed less sleep than usual
         

Indicate whether any of the above symptoms:

24 .
Interferes with work or school
         
25 .
Affects my relationships with friends or family
         
26 .
Has led to my using alcohol to get by
         
27 .
Has led to my using drugs
         

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This form is not a diagnostic instrument and is to be used solely within the context of your medical treatment with your physician or other health care provider. The maker and provider of this form disclaims any liability, loss, or risk incurred as a consequence, directly or indirectly, from the use and application of any of this material. My Mood Monitor™ V.03.06 Copyright © 2002-2012 by M3 Information™, The M-3 Checklist and Mymoodmonitor.com are free for personal home use. For any other uses, including clinical., educational, non-profit, hospital research, or for-profit settings please contact mail@m-3information.com. No further reproduction or distribution, or reverse engineering is permitted without written permission from M3 Information. Patent Pending.