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Assessment Form
DATE (MM/DD/YYYY)
1. On a 1-10 scale, during the past month how much of the time were you a happy person?
10-All of the time
9
8
7
6
5
4
3
2
1-None of the time
2. On a 1-10 scale, How much of the time during the past month have you felt calm and peaceful?
10-All of the time
9
8
7
6
5
4
3
2
1-None of the time
3. On a 1-10 scale, How much of the time, during the past month, have you been a very nervous person?
10-All of the time
9
8
7
6
5
4
3
2
1-None of the time
4. On a 1-10 scale, How much of the time, during the past month, have you felt downhearted and blue?
10-All of the time
9
8
7
6
5
4
3
2
1-None of the time
5. On a 1-10 scale, How much of the time during the past month, have you felt so down in the dumps that nothing could cheer you up?
10-All of the time
9
8
7
6
5
4
3
2
1-None of the time
6. Rate the overall quality of your sleep
10-Very poor
9
8
7
6
5
4
3
2
1-Very good
7. Rate the overall quality of your stress management
10-Very poor
9
8
7
6
5
4
3
2
1-Very good
8. Rate your overall quality of cognitive function (reading, thinking, reasoning, calculation)
10-Very poor
9
8
7
6
5
4
3
2
1-Very good
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