Watermark Assessment InstructionsWatermark Assessment Patient Health QuestionnaireName Name First First Last Last Clinician Date 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 (0) Not at all (1) Several days (2) More than half the days (3) Nearly every day2. Feeling down, depressed, or hopeless (0) Not at all (1) Several days (2) More than half the days (3) Nearly every day3. Trouble falling asleep, staying asleep, or sleeping too much? (0) Not at all (1) Several days (2) More than half the days (3) Nearly every day4. Feeling tired, or having little energy? (0) Not at all (1) Several days (2) More than half the days (3) Nearly every day5. Poor appetite, weight loss, or overeating? (0) Not at all (1) Several days (2) More than half the days (3) Nearly every day6. Feeling bad about yourself - or feeling that you are a failure, or that you have let yourself or your family down? (0) Not at all (1) Several days (2) More than half the days (3) Nearly every day7. Trouble concentrating on things, such as reading the newspaper or watching television (0) Not at all (1) Several days (2) More than half the days (3) Nearly every day8. 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? (0) Not at all (1) Several days (2) More than half the days (3) Nearly every day9. Thoughts that you would be better off dead, or of hurting yourself in some way? (0) Not at all (1) Several days (2) More than half the days (3) Nearly every dayIf 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? Not difficult at all Somewhat difficult Very difficult Extremely difficultZung Anxiety Self-Assessment ScaleFor each item below, please select which option best describes how often you felt or behaved this way during the past several days1. I feel more nervous and anxious than usual (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time2. I feel afraid for no reason at all (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time3. I get upset easily or feel panicky (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time4. I feel like I'm falling apart and going to pieces (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time5. I feel that everything is all right and nothing bad will happen (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time6. My arms and legs shake and tremble (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time7. I am bothered by headaches, neck and back pains (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time8. I feel weak and get tired easily (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time9. I feel calm and can sit still easily (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time10. I can feel my heart beating fast (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time11. I am bothered by dizzy spells (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time12. I have fainting spells or feel faint (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time13. I can breath in and out easily (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time14. I get feelings of numbness and tingling in my fingers and toes (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time15. I am bothered by stomachaches or indigestion (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time16. I have to empty my bladder often (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time17. My hands are usually dry and warm (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time18. My face gets hot and blushes (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time19. I fall asleep easily and get a good night's rest (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time20. I have nightmares (1) None or a little of the time (2) Some of the time (3) Good part of the time (4) Most or all of the time Please add up your score for all boxes checked Epworth Sleepiness ScaleThe 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 (0) Would never doze or sleep (1) Slight chance of dozing or sleeping (2) Moderate chance of dozing or sleeping (3) High chance of dozing or sleepingWatching TV (0) Would never doze or sleep (1) Slight chance of dozing or sleeping (2) Moderate chance of dozing or sleeping (3) High chance of dozing or sleepingSitting inactive in a public place (0) Would never doze or sleep (1) Slight chance of dozing or sleeping (2) Moderate chance of dozing or sleeping (3) High chance of dozing or sleepingBeing a passenger in a motor vehicle for an hour or more (0) Would never doze or sleep (1) Slight chance of dozing or sleeping (2) Moderate chance of dozing or sleeping (3) High chance of dozing or sleepingLying down in the afternoon (0) Would never doze or sleep (1) Slight chance of dozing or sleeping (2) Moderate chance of dozing or sleeping (3) High chance of dozing or sleepingSitting and talking to someone (0) Would never doze or sleep (1) Slight chance of dozing or sleeping (2) Moderate chance of dozing or sleeping (3) High chance of dozing or sleepingSitting quietly after lunch (no alcohol) (0) Would never doze or sleep (1) Slight chance of dozing or sleeping (2) Moderate chance of dozing or sleeping (3) High chance of dozing or sleepingStopped for a few minutes in traffic while driving (0) Would never doze or sleep (1) Slight chance of dozing or sleeping (2) Moderate chance of dozing or sleeping (3) High chance of dozing or sleeping Total score (add the scores up) Additional Sleep InformationDo you have difficulty Initiating sleep? Yes NoDo you have difficulty maintaining sleep? Yes NoDo you experience early morning awakening with inability to return to sleep? Yes NoDo these difficulties occur at least three nights per week? Yes NoHave these difficulties been present for at least three months? Yes No Numeric Physical Pain Rating Scale 0 1 2 3 4 5 6 7 8 9 10Please select which option best describes your pain, with 0 being no pain, and 10 being the worst possible pain. If you are human, leave this field blank. Submit