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Nathan Ezzo, Licsw

greater elevations Counseling PLLC

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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 *

0

1

2

3

4

Feeling unhappy or blue *

0

1

2

3

4

Crying spells or tearfulness *

0

1

2

3

4

Feeling discouraged *

0

1

2

3

4

Feeling hopeless *

0

1

2

3

4

Low Self-esteem *

0

1

2

3

4

Feeling worthless or inadequate *

0

1

2

3

4

Guilt or Shame *

0

1

2

3

4

Criticizing yourself or blaming yourself *

0

1

2

3

4

Difficulty making decisions *

0

1

2

3

4

Activities and Personal Relationships

Loss of interest in family, friends or colleagues *

0

1

2

3

4

Loneliness *

0

1

2

3

4

Spending less time with family/friends *

0

1

2

3

4

Loss of motivation *

0

1

2

3

4

Loss of interest in work/other activities *

0

1

2

3

4

Avoiding work/other activities *

0

1

2

3

4

Loss of pleasure/satisfaction in life *

0

1

2

3

4

Physical Symptoms

Feeling tired *

0

1

2

3

4

Difficulty sleeping or sleeping too much *

0

1

2

3

4

Decreased or increased appetite *

0

1

2

3

4

Loss of interest in sex *

0

1

2

3

4

Worrying about your health *

0

1

2

3

4

Suicidal Urges

Do you have any suicidal thoughts? *

0

1

2

3

4

Would you like to end your life? *

0

1

2

3

4

Do you have a plan for harming yourself? *

0

1

2

3

4

ANXIETY SCALE

Thoughts and Feelings

Feeling anxious *

0

1

2

3

4

Feeling overly worried *

0

1

2

3

4

Crying or tearfulness *

0

1

2

3

4

Discouraged *

0

1

2

3

4

Feeling panic *

0

1

2

3

4

Decrease Self-esteem *

0

1

2

3

4

Feeling overwhelmed *

0

1

2

3

4

Dwelling or ruminating thoughts *

0

1

2

3

4

Criticizing or blaming yourself *

0

1

2

3

4

Struggle to make decisions *

0

1

2

3

4

Activities and Personal Relationships

Anxiety kept you from engaging with friends/family *

0

1

2

3

4

Isolated *

0

1

2

3

4

Difficulty concentrating in activities *

0

1

2

3

4

Avoided work/other activities *

0

1

2

3

4

Loss of pleasure or satisfaction *

0

1

2

3

4

Physical Symptoms

Level of feeling tired *

0

1

2

3

4

Sleeping too much or not enough *

0

1

2

3

4

Increase or decrease in appetite *

0

1

2

3

4

Loss of sex interest *

0

1

2

3

4

Experienced tightness in chest *

0

1

2

3

4

Tension in muscles *

0

1

2

3

4

Shortness of breath *

0

1

2

3

4

Suicidal Urges

Level of suicidal thoughts? *

0

1

2

3

4

Thinking to end your life? *

0

1

2

3

4

A plan for harming yourself? *

0

1

2

3

4

Name

Please answer all questions.

Contact

Greater Elevations Counseling PLLC

839 SW 126TH ST

Burien, WA 98146

Tel: 253-777-1540

gecounseling19@gmail.com

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