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About
On Your Mark Nutrition
Precision Dietetics & Nutrition
Concierge Nutrition
Sport Performance
Functional Nutrition
Investigative Nutrition
Testimonials
Frequently Asked Questions
Policies
Team
Katie Mark
Dr. Lorenzo Gonzalez
Concierge Services
Sport Performance Nutrition
Functional Nutrition for Fitness, Health & Wellness
Investigative Nutrition
Testing
Education
Blog
Guest Articles
Guest Blogs
Tufts Nutrition
Contact
Client Login
Cognition Questionnaire
Mind/Cognition
Questionnaire
Directions
: Please fill out all questions. Choose the answer that best describes your feeling.
Name
*
First Name
Last Name
Comments
Question 1
*
I do not feel sad.
I feel sad.
I am sad all the time and I can't snap out of it.
I am so sad and unhappy that I can't stand it.
Question 2
*
I am not particularly discouraged about the future.
I feel discouraged about the future.
I feel I have nothing to look forward to.
I feel the future is hopeless and that things cannot improve.
Question 3
*
I do not feel like a failure.
I feel I have failed more than the average person.
As I look back on my life, all I can see is a lot of failures.
I feel I am a complete failure as a person.
Question 4
*
I get as much satisfaction out of things as I used to.
I don't enjoy things the way I used to.
I don't get real satisfaction out of anything anymore.
I am dissatisfied or bored with everything.
Question 5
*
I don't feel particularly guilty.
I feel guilty a good part of the time.
I feel quite guilty most of the time.
I feel guilty all of the time.
Question 6
*
I don't feel I am being punished.
I feel I may be punished.
I expect to be punished.
I feel I am being punished.
Question 7
*
I don't feel disappointed in myself.
I am disappointed in myself.
I am disgusted with myself.
I hate myself.
Question 8
*
I don't feel I am any worse than anybody else.
I am critical of myself for my weaknesses or mistakes.
I blame myself all the time for my faults.
I blame myself for everything bad that happens.
Question 9
*
I don't have any thoughts of killing myself.
I have thoughts of killing myself, but I would not carry them out.
I would like to kill myself.
I would kill myself if I had the chance.
Question 10
*
I don't cry any more than usual.
I cry more now than I used to.
I cry all the time now.
I used to be able to cry, but now I can't cry even though I want to.
Question 11
*
I am no more irritated by things than I ever was.
I am slightly more irritated now than usual.
I am quite annoyed or irritated a good deal of the time. I feel irritated all the time.
Question 12
*
I have not lost interest in other people.
I am less interested in other people than I used to be. I have lost most of my interest in other people.
I have lost all of my interest in other people.
Question 13
*
I make decisions about as well as I ever could.
I put off making decisions more than I used to.
I have greater difficulty in making decisions more than I used to.
I can't make decisions at all anymore.
Question 14
*
I don't feel that I look any worse than I used to.
I am worried that I am looking old or unattractive.
I feel there are permanent changes in my appearance that make me look unattractive.
I believe that I look ugly.
Question 15
*
I can work about as well as before.
It takes an extra effort to get started at doing something. I have to push myself very hard to do anything.
I can't do any work at all.
Question 16
*
I can sleep as well as usual.
I don't sleep as well as I used to.
I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.
I wake up several hours earlier than I used to and cannot get back to sleep.
Question 17
*
I don't get more tired than usual.
I get tired more easily than I used to.
I get tired from doing almost anything.
I am too tired to do anything.
Question 18
*
My appetite is no worse than usual.
My appetite is not as good as it used to be.
My appetite is much worse now.
I have no appetite at all anymore.
Question 19
*
I haven't lost much weight, if any, lately.
I have lost more than five pounds.
I have lost more than ten pounds.
I have lost more than fifteen pounds.
Question 20
*
I am no more worried about my health than usual.
I am worried about physical problems like aches, pains, upset stomach or constipation.
I am very worried about physical problems and it's hard to think of much else.
I am so worried about my physical problems that I cannot think of anything else.
Question 21
*
I have not noticed any recent change in my interest in sex.
I am less interested in sex than I used to be.
I have almost no interest in sex.
I have lost interest in sex completely.
Thank you!