Depression

CES-D

Below is a list of some of ways you may have felt or behaved before.
Please check the box to indicate how often you have felt this way during the past week.

1. I was bothered by things that usually do not bother me.
2. I did not feel like eating; my appetite was poor.
3. I felt that I could not shake off the blues, even with help from my family or friends.
4. I felt that I was just as good as other people.
5. I had trouble keeping my mind on what I was doing.
6. I felt depressed.
7. I felt that everything I did was an effort.
8. I felt hopeful about the future.
9. I thought my life had been a failure.
10. I felt fearful.
11. My sleep was restless.
12. I was happy.
13. I talked less than usual.
14. I felt lonely.
15. People were unfriendly.
16. I enjoyed life.
17. I had crying spells.
18. I felt sad.
19. I felt that people disliked me.
20. I could not get going.

Anxiety

STAI-short form

A number of statements which people have used to describe themselves are given below. Please read each statement and then mark the most appropriate choice to the right of the statement to indicate how you feel right now, at this moment. There are no right or wrong answers. Do not spend too much time any one statement but give the answer which seems to describe your present feelings best.

1. I feel calm.
2. I am tense.
3. I feel upset.
4. I am relaxed.
5. I feel content.
6. I am worried.

Stress

Pain

BPI-short form

Brief pain inventory

1. Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and toothacthes). Have you had pain other than these everyday kinds of pain today?
2. On the diagram, choose the areas where you feel pain. (temp)
bpi front-1 front-2 front-3 front-4 front-5 front-6 front-7 back-1 back-2
3. Please rate your pain by choosing the scale that best describes your pain at its worst in the last 24 hours.
5
4. Please rate your pain by choosing the scale that best describes your pain at its least in the last 24 hours.
5
5. Please rate your pain by choosing the scale that best describes your pain on average.
5
6. Please rate your pain by choosing the scale that tells how much pain you have right now.
5
7. What treatments or medications are you receiving for your pain?
8. In the last 24 hours, how much relief have pain treatments or medications provided? Please choose the percentage that most shows how much relief you have received.
50%
9. Choose the scale that describes how, during the past 24 hours, pain has interfered with your:
A. General Activity
5
B. Mood
5
C. Walking Ability
5
D. Normal Work(includes both work outside the home and housework)
5
E. Relations with other people
5
F. Sleep
5
G. Enjoyment of life
5

(Copyright © 1991 Charles S. Cleeland, PhD, Pain Research Group. All rights reserved.)

Fatigue

FACIT-Fatigue Scale

Please read the following statements about fatigue. Use the scale to indicate how often you have felt that way during the past week.

1. I feel fatigued.
2. I feel weak all over.
3. I feel listless('washed out').
4. I feel tired.
5. I have trouble starting things because I am tired.
6. I have trouble finishing things because I am tired.
7. I have energy.
8. I am able to do my usual activities.
9. I need to sleep during the day.
10. I am too tired to eat.
11. I need help doing my usual activities.
12. I am frustrated by being too tired to do the things I want to do.
13. I have to limit my social activity because I am tired.

Sleep

Pittsburgh Sleep Quality Index (PSQI)

The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of days and nights in the past month. Please answer all questions.

1. During the past month, when have you usually gone to bed at night?
2. During the past month, how long (in minutes) has it usually take you to fall asleep each night?
3. During the past month, when have you usually gotten up in the morning?
4. During the past month, how many hours of actual sleep did you get at night? (This may be different than the number of hours you spend in bed.)

For each of the remaining questions, check the one best response. Please answer all questions.

5. During the past month, how often have you had trouble sleeping because you...
Not during the past month Less than once a week Once or twice a week Three or more times a week
(a) ...cannot get to sleep within 30 minutes
(b) ...wake up in the middle of the night or early morning
(c) ...have to get up to use the bathroom
(d) ...cannot breathe comfortably
(e) ...cough or snore loudly
(f) ...feel too cold
(g) ...feel too hot
(h) ...had bad dreams
(i) ...have pain
6. During the past month, how would you rate your sleep quality overall?
7. During the past month, how often have you taken medicine (prescribed or "over the counter") to help you sleep?
8. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?
9. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?
10. Do you have a roommate or bed partner?

Relationship Satisfaction

DAS-7

Most persons have disagreements in their relationships. Please indicate below the approximate extent of agreement or disagreement between you and your partner for each item on the following list.

1. Philosophy of life:
2. Aims, goals, and things believed important:
3. Amount of time spent together:

How often would you say the following events occur between you and your mate?

4. Have a stimulating exchange of ideas:
5. Calmly discuss something together:
6. Work together on a project:
7. The following scales represent different degrees of happiness in your relationship. The middle point "happy" represents the degree of happiness of most relationships. Please choose the scale which best describes the degree of happiness, all things considered, of your relationship.

© 2024 Center for Excellence in Behavioral Medicine, UPMC