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Site MR #:
Site Name:
Patient Initials:
PID:
Visit: Screening/Baseline
Date:
Week 6
Week 12
Items
Question 1
Question 3
Question 5
Question 7
Question 9
Question 11
Question 13
Score = ______
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Site MR #:
Site Name:
Patient Initials:
PID:
Visit: Screening/Baseline
Date:
Week 6
Week 12
Response Choices
3 Most of the time
2 A lot of the time
2 Only a little
3 Hardly at all
3 Very definitely and quite badly
6. I feel cheerful.
1 Sometimes
0 Most of the time
0 Definitely
1 Usually
2 Not often
3 Not at all
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Site MR #:
Site Name:
Patient Initials:
PID:
Visit: Screening/Baseline
Date:
Week 6
Week 12
1 Sometimes
0 Not at all
0 Not at all
1 Occasionally
2 Quite often
3 Very often
3 Definitely
2 I dont take as much care as I should
2 Quite a lot
1 Not very much
0 Not at all
0 As much as I ever did
1 Rather less than I used to
Not at all
0 Often
1 Sometimes
14. I can enjoy a good book or TV program.
2 Not often
3 Very seldom
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