Emotional Assessment

Circle yes or no for each question.
 

Do you have trouble sleeping?
 

YES

No

Has your appetite diminished?
 

YES

No

Do you cry often?
 

YES

No

Do you worry a lot?
 

YES

No

Do you have trouble concentrating?
 

YES

No

Are you basically satisfied with your life?
 

Yes

NO

Have you dropped many of your activities and interests?
 

YES

No

Do you feel that your life is empty?
 

YES

No

Do you often get bored?
 

YES

No

Are you in good spirits most of the time?
 

Yes

NO

Are you afraid that something bad is going to happen to you?
 

YES

No

Do you feel happy most of the time?
 

Yes

NO

Do you often feel helpless?
 

YES

No

Do you prefer to stay at home, rather than going out and doing new things?
 

YES

No

Do you feel you have more problems with memory than most?
 

YES

No

Do you think it is wonderful to be alive now?
 

Yes

NO

Do you feel pretty worthless the way you are now?
 

YES

No

Do you feel full of energy?
 

Yes

NO

Do you feel that your situation is hopeless?
 

YES

No

Do you think that most people are better off than you are?

YES

No

Copyright 2004.  Robert S. Stall, MD / Stall Geriatrics.  All Rights Reserved.