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Search Smokefree 60 Plus
Check the response to each item that best describes you for the past 7 days.
1. Falling asleep
I never take longer than 30 minutes to fall asleep.
I take at least 30 minutes to fall asleep, less than half the time.
I take at least 30 minutes to fall asleep, more than half the time.
I take more than 60 minutes to fall asleep, more than half the time.
2. Sleep during the night
I do not wake up at night.
I have a restless light sleep with a few brief awakenings each night.
I wake up at least once a night, but I go back to sleep easily.
I awaken more than once a night and stay awake for 20 minutes or more, more than half the time.
3. Waking up too early
Most of the time, I wake up no more than 30 minutes before I need to get up.
More than half the time, I wake up more than 30 minutes before I need to get up.
I almost always wake up at least 1 hour or so before I need to, but I go back to sleep eventually.
I wake up at least 1 hour before I need to, and can't go back to sleep.
4. Sleeping too much
I sleep no longer than 7-8 hours a night without napping during the day.
I sleep no longer than 10 hours in a 24 hour period including naps.
I sleep no longer than 12 hours in a 24 hour period including naps.
I sleep longer than 12 hours in a 24 hour period including naps.
5. Feeling sad
I do not feel sad.
I feel sad less than half the time.
I feel sad more than half the time.
I feel sad nearly all the time.
There is no change in my usual appetite.
I've lost my appetite.
I'm eating too much.
6a. Decreased appetite
I eat somewhat less often or smaller amounts of food than usual.
I eat much less than usual and only by forcing myself to eat.
I rarely eat within a 24 hour period and only by really forcing myself to eat or when others persuade me to eat.
6b. Increased appetite
I feel a need to eat more frequently than usual.
I regularly eat more often and/or greater amounts of food than usual.
I feel driven to overeat both at mealtime and between meals.
I have not had a change in my weight.
I've lost weight.
I've gained weight.
7a. Decreased weight (within the last 2 weeks)
I feel as if I have had a slight weight loss.
I have lost 2 pounds or more.
I have lost 5 pounds or more.
7b. Increased weight (within the last 2 weeks)
I feel as if I have had a slight weight gain.
I have gained 2 pounds or more.
I have gained 5 pounds or more.
8. Concentration/decision making
There is no change in my usual capacity to concentrate or make decisions.
I occasionally feel indecisive or find that my attention wanders.
Most of the time I struggle to focus my attention or to make decisions.
I cannot concentrate well enough to read or make minor decisions.
9. View of myself
I see myself as equally worthwhile and deserving as other people.
I am more self-blaming than usual.
I largely believe that I cause problems for others.
I think almost constantly about major and minor defects in my life.
10. Thoughts of suicide or death
I do not think of suicide or death.
I feel that life is empty and wonder if it's worth living.
I think of suicide or death several times a week for several minutes.
I think of suicide or death several times a day in some detail, or I have made specific plans for suicide or have actually tried to take my life.
11. General interest
There is no change from usual in how interested I am in other people or activities.
I notice that I am less interested in people or activities.
I find I have interest in only one or two of my formerly pursued activities.
I have virtually no interest in formerly pursued activities.
12. Energy level
There is no change in my usual level of energy.
I get tired more easily than usual.
I have to make a big effort to start or finish my usual daily activities (for example: shopping, cooking, or going to work).
I cannot carry out most of my usual daily activities because I don't have the energy.
13. Feeling restless
I do not feel restless.
I'm often fidgety, wringing my hands, or need to shift how I am sitting.
I have impulses to move about and am quite restless.
At times, I am unable to stay seated and need to pace around.
14. Feeling slowed down
I think, speak and move at my usual rate of speed.
I find that my thinking is slowed down or my voice sounds dull or flat.
It takes me several seconds to respond to most questions and I am sure my thinking is slowed.
I am often unable to respond to questions without extreme effort.