K5 Assessment form
Client's First Name:
Client's Last Name:
In the last four weeks, about how often did you feel nervous?
--None--
All of the time
Most of the time
Some of the time
A little of the time
None of the time
In the last four weeks, about how often did you feel without hope?
--None--
All of the time
Most of the time
Some of the time
A little of the time
None of the time
In the last four weeks, about how often did you feel restless or jumpy?
--None--
All of the time
Most of the time
Some of the time
A little of the time
None of the time
In the last four weeks, about how often did you feel everything was an effort?
--None--
All of the time
Most of the time
Some of the time
A little of the time
None of the time
In the last four weeks, about how often did you feel so sad that nothing could cheer you up?
--None--
All of the time
Most of the time
Some of the time
A little of the time
None of the time
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