Burns Depression Checklist and Anxiety Scale

Indicate how much you have experienced each symptom during the past week, including today. 

(0-Not at all, 1-Sometimes, 2-Moderately, 3-A lot, 4-Extremely)

All questions must be completed.

DEPRESSION CHECKLIST

Thoughts and Feelings

Feeling sad or down in the dumps
Feeling unhappy or blue
Crying spells or tearfulness
Feeling discouraged
Feeling hopeless
Low Self-esteem
Feeling worthless or inadequate
Guilt or Shame
Criticizing yourself or blaming yourself
Difficulty making decisions

Activities and Personal Relationships

Loss of interest in family, friends or colleagues
Loneliness
Spending less time with family/friends
Loss of motivation
Loss of interest in work/other activities
Avoiding work/other activities
Loss of pleasure/satisfaction in life

Physical Symptoms

Feeling tired
Difficulty sleeping or sleeping too much
Decreased or increased appetite
Loss of interest in sex
Worrying about your health

Suicidal Urges

Do you have any suicidal thoughts?
Would you like to end your life?
Do you have a plan for harming yourself?

ANXIETY SCALE

Thoughts and Feelings

Feeling anxious
Feeling overly worried
Crying or tearfulness
Discouraged
Feeling panic
Decrease Self-esteem
Feeling overwhelmed
Dwelling or ruminating thoughts
Criticizing or blaming yourself
Struggle to make decisions

Activities and Personal Relationships

Anxiety kept you from engaging with friends/family
Isolated
Difficulty concentrating in activities
Avoided work/other activities
Loss of pleasure or satisfaction

Physical Symptoms

Level of feeling tired
Sleeping too much or not enough
Increase or decrease in appetite
Loss of sex interest
Experienced tightness in chest
Tension in muscles
Shortness of breath

Suicidal Urges

Level of suicidal thoughts?
Thinking to end your life?
A plan for harming yourself?

Please answer all questions.