Michele Ashdown, LCSW, ch

Individual, Couple and Family Counseling

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Burns' Depression Checklist*

INSTRUCTIONS: Select the appropriate option to indicate how much each of the symptoms has been bothering you in the past week including today. Please be honest and be sure to answer all 15 questions.

Sadness: Have you been feeling sad or down in the dumps?

Not at All (0 Days per Week)

Somewhat (1-2 Days per Week)

Moderately (3-4 Days per Week)

A Lot (5-7 Days per Week)

Discouragement: Does the future look bleak or hopeless?

Not at All (0 Days per Week)

Somewhat (1-2 Days per Week)

Moderately (3-4 Days per Week)

A Lot (5-7 Days per Week)

Low Self-Esteem: Do you feel worthless or think of yourself as a loser?

Not at All (0 Days per Week)

Somewhat (1-2 Days per Week)

Moderately (3-4 Days per Week)

A Lot (5-7 Days per Week)

Inferiority: Do you feel inadequate or inferior to others?

Not at All (0 Days per Week)

Somewhat (1-2 Days per Week)

Moderately (3-4 Days per Week)

A Lot (5-7 Days per Week)

Guilt: Do you get self-critical and blame yourself?

Not at All (0 Days per Week)

Somewhat (1-2 Days per Week)

Moderately (3-4 Days per Week)

A Lot (5-7 Days per Week)

Indecisiveness: Is it hard to make decisions?

Not at All (0 Days per Week)

Somewhat (1-2 Days per Week)

Moderately (3-4 Days per Week)

A Lot (5-7 Days per Week)

Irritability and Frustration: Have you been feeling angry or resentful?

Not at All (0 Days per Week)

Somewhat (1-2 Days per Week)

Moderately (3-4 Days per Week)

A Lot (5-7 Days per Week)

Loss of Motivation: Do you feel overwhelmed and have to push yourself hard to do things?

Not at All (0 Days per Week)

Somewhat (1-2 Days per Week)

Moderately (3-4 Days per Week)

A Lot (5-7 Days per Week)

Poor Self-Image: Do you think you're looking old or unattractive

Not at All (0 Days per Week)

Somewhat (1-2 Days per Week)

Moderately (3-4 Days per Week)

A Lot (5-7 Days per Week)

Appetite Changes: Have you lost your appetite? Or, do you over eat compulsively?

Not at All (0 Days per Week)

Somewhat (1-2 Days per Week)

Moderately (3-4 Days per Week)

A Lot (5-7 Days per Week)

Sleep Changes: Is it hard to get a good night's sleep? Or, are you tired and sleeping too much?

Not at All (0 Days per Week)

Somewhat (1-2 Days per Week)

Moderately (3-4 Days per Week)

A Lot (5-7 Days per Week)

Loss of Libido: Have you lost your interest in sex?

Not at All (0 Days per Week)

Somewhat (1-2 Days per Week)

Moderately (3-4 Days per Week)

A Lot (5-7 Days per Week)

Hypochondriasis: Do you worry a lot about your health?

Not at All (0 Days per Week)

Somewhat (1-2 Days per Week)

Moderately (3-4 Days per Week)

A Lot (5-7 Days per Week)

Suicidal Impulses: Do you think life is not worth living or think you'd be better off dead?

Not at All (0 Days per Week)

Somewhat (1-2 Days per Week)

Moderately (3-4 Days per Week)

A Lot (5-7 Days per Week)

Contact

1581 N 4325 W

Plain City, UT 84404

Phone (801) 698-4006

Fax (801) 730-7171

micheleashdown@gmail.com

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