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Watermark Assessment Instructions

Watermark Assessment

Patient Health Questionnaire

Name
Name
First
Last
Instructions: How often have you been bothered by each of the following symptoms during the past two weeks?
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling asleep, staying asleep, or sleeping too much?
4. Feeling tired, or having little energy?
5. Poor appetite, weight loss, or overeating?
6. Feeling bad about yourself - or feeling that you are a failure, or that you have let yourself or your family down?
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you were moving around a lot more than usual?
9. Thoughts that you would be better off dead, or of hurting yourself in some way?
If you are experiencing any of the problems on this form, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?

Zung Anxiety Self-Assessment Scale

For each item below, please select which option best describes how often you felt or behaved this way during the past several days
1. I feel more nervous and anxious than usual
2. I feel afraid for no reason at all
3. I get upset easily or feel panicky
4. I feel like I'm falling apart and going to pieces
5. I feel that everything is all right and nothing bad will happen
6. My arms and legs shake and tremble
7. I am bothered by headaches, neck and back pains
8. I feel weak and get tired easily
9. I feel calm and can sit still easily
10. I can feel my heart beating fast
11. I am bothered by dizzy spells
12. I have fainting spells or feel faint
13. I can breath in and out easily
14. I get feelings of numbness and tingling in my fingers and toes
15. I am bothered by stomachaches or indigestion
16. I have to empty my bladder often
17. My hands are usually dry and warm
18. My face gets hot and blushes
19. I fall asleep easily and get a good night's rest
20. I have nightmares

Epworth Sleepiness Scale

The Epworth Sleepiness Scale is used to determine the level of daytime sleepiness. A score of 10 or more is considered sleepy. A score of 18 or more is very sleepy. If you score 10 or more on this test, your should consider whether you are obtaining adequate sleep, or need to improve your sleep hygiene.
Sitting and reading
Watching TV
Sitting inactive in a public place
Being a passenger in a motor vehicle for an hour or more
Lying down in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (no alcohol)
Stopped for a few minutes in traffic while driving

Additional Sleep Information

Do you have difficulty Initiating sleep?
Do you have difficulty maintaining sleep?
Do you experience early morning awakening with inability to return to sleep?
Do these difficulties occur at least three nights per week?
Have these difficulties been present for at least three months?
Please select which option best describes your pain, with 0 being no pain, and 10 being the worst possible pain.