Welcome to this survey. Press Next to begin.

The following questions ask about how you have been feeling during the past 30 days. For each question, please select the option that best describes how often you had this feeling.

Q1: During the past 30 days, about how often did you feel …

… nervous?

All of the time Most of the time Some of the time A little of the time None of the time

… hopeless?

All of the time Most of the time Some of the time A little of the time None of the time

… restless or fidgety?

All of the time Most of the time Some of the time A little of the time None of the time

… so depressed that nothing could cheer you up?

All of the time Most of the time Some of the time A little of the time None of the time

… that everything was an effort?

All of the time Most of the time Some of the time A little of the time None of the time

… worthless?

All of the time Most of the time Some of the time A little of the time None of the time

Q2: The last six questions asked about feelings that might have occurred during the past 30 days. Taking them altogether, did these feelings occur more often in the past 30 days than is usual for you, about the same as usual, or less often than usual? (If you never have any of these feelings, select “about the same as usual”)

A lot Some
More often than usual
← A little About the same as usual A little Some
Less often than usual
→ A lot

The next few questions are about how these feelings may have affected you in the past 30 days. You need not answer these questions if you answered “None of the time” to all of the six questions about your feelings.

Q3: During the past 30 days, how many days out of 30 were you totally unable to work or carry out your normal activities because of these feelings?

(Number of Days)

Q4: Not counting the days you reported in response to Q3, how many days in the past 30 were you able to do only half or less of what you would normally have been able to do, because of these feelings?

(Number of Days)

Q5: During the past 30 days, how many times did you see a doctor or other health professional about these feelings?

(Number of Times)

Q6: During the past 30 days, how often have physical health problems been the main cause of these feelings?

All of the time Most of the time Some of the time A little of the time None of the time

Do you have or have you ever been diagnosed with any of the following psychological disorders (check all that apply)?

ADHD Alcohol Dependency Anorexi Nervosa Anxiety Disorder Autism/Autism Specturm Disorder Borderline Personality Disorder Bulimia Drug Dependency Depression Manic-Depressive (Bilpolar) illness Obessive Compulsive Disorder Schizophrenia Other None

If you responded “other” to the above question, please describe:

Have you been diagnosed with any neurological disorder (e.g. Alzheimer's, Parkinson's)?

Yes No

If you responded “yes” to the above question, please describe:

Do you have or have you ever been diagnosed with any of the following medical conditions (check all that apply)?

Type II diabetes Metabolic Syndrome High Blood Pressure Heart Disease Stroke Cancer Sleep Apnea Other None

If you responded “other” to the above question, please describe:

Congratulations for completing this survey! Press finish to continue.