*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

HAVE YOU RECENTLY:
1. Been feeling perfectly well and in good health?
2. Been feeling in need of a good tonic?
3. Been feeling run down and out of sorts?
4. Felt that you are ill?
5. Been getting any pains in your head?
6. Been getting a feeling of tightness or pressure in your
7. Been having hot or cold spells?
8. Lost much sleep over worry?
9. Had difficulty staying asleep once you are off?
10. Been managing to keep yourself busy and occupied?
11. Been taking longer over the things you do?
12. Felt on the whole you were doing things well?
13. Been satisfied with the way you’ve carried out your task?
14. Felt that you are playing a useful part in things?
15. Felt capable of making decisions about things?
16. Felt constantly under strain?
17. Been able to enjoy your normal day-to-day activities?
18. Been getting edgy and bad-tempered?
19. Been getting scared or panicky for no good reason?
20. Found everything getting on top of you?
21. Been thinking of yourself as a worthless person?
22. Felt that life is entirely hopeless?
23. Been feeling nervous and strung-up all the time?
24. Felt that life isn’t worth living?
25. Thought of the possibility that you might make away with yourself?
26. Found at times you couldn’t do anything because your nerves were too bad?
27. Found yourself wishing you were dead and away from it all?
28. Found that the idea of taking your life kept coming into your mind?

For all questions the following response scale is used:
Better than usual 1
Same as usual 2
Worse than usual 3
Much worse than usual 4

OR

Not at all 1
No more than usual 2
Rather more than usual 3
Much more than usual 4

DEPENDING ON WHICH IS APPROPRIATE