How Do You Feel? — Acorn Counseling LLC

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How much did the following problems bother you?

For questions 1-16, please think about your experience in the past week.

1. Nervousness or Shakiness

2. Feeling sad or blue

3. Feeling hopeless about the future

4. Feeling everything is an effort

5. Feeling no interest in things

6. Your heart pounding or racing

7. Trouble sleeping

8. Feeling fearful or afraid

9. Difficulty at home

10. Difficulty socially

11. Difficulty at work or school

How much do you agree with the following?

16. In the past week, approximately how many drinks of alcohol did you have?

Please answer the following questions only if this is your first time completing this questionnaire.

20. In the past month, how many days were you unable to work because of your physical or mental health?

Answer only if employed

21. In the past month, how many days were you able to work but had to cut back on how much you got done because of your physical or mental health?

Answer only if employed

Survey: How do you feel?