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Couples–SDS Intake Questionnaire

Name *

First

Last

I feel down-hearted, blue and sad. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

Morning is when I feel the best. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

I have crying spells or feel like it. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

I have trouble sleeping through the night. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

I eat as much as I used to. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

I enjoy looking at, talking to and being with attractive women/men. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

I notice that I am losing weight. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

I have trouble with constipation. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

My heart beats faster than usual. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

I get tired for no reason. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

My mind is as clear as it used to be. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

I find it easy to do the things I used to do. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

I am restless and can't keep still. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

I feel hopeful about the future. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

I am more irritable than usual. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

I find it easy to make decisions. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

I feel that I am useful and needed. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

My life is pretty full. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

I feel that others would be better off if I were dead. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

I still enjoy the things I used to do. *

None or a little of the time
Some of the time
A good part of the time
Most or all of the time

Date *

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