K10 Assessment Form

1. In the last four weeks, about how often did you feel tired out for no good reason?

2. In the last four weeks, about how often did you feel nervous?

3. In the last four weeks, about how often did you feel so nervous that nothing could calm you down?

4. In the last four weeks, about how often did you feel hopeless?

5. In the last four weeks, about how often did you feel restless or fidgety?

6. In the last four weeks, about how often did you feel so restless you could not sit still?

7. In the last four weeks, about how often did you feel depressed?

8. In the last four weeks, how often did you feel everything was an effort?

9. In the last four weeks, about how often did you feel so sad nothing could cheer you up?:

10. In the last four weeks, about how often did you feel worthless?:

11. In the past four weeks, how many days were you totally unable to work, study or manage your day to day activities due to these feelings?

12. Aside from those days, in the past four weeks, how many days were you able to work or study or manage your day to day activities, but had to cut down on what you did because of these feelings?

13. In the last four weeks, how many times have you seen a doctor or any health professional about these feelings?

14. In the past four weeks, how often have physical health problems been the main cause of these feelings?