Name
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First Name
Last Name
Email
*
Phone
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(###)
###
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Gender
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Male
Female
Citadel Status
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Student
Cadet
MECEP
Veteran
Faculty
In the last 30 days, how many have you exercised?
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How many days a week do you currently exercise?
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1. Having little interest or pleasure in doing things
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2. Feeling down, depressed, or hopeless
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3. Trouble falling asleep or staying asleep, or sleeping too
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4. Feeling tired or having little energy
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5. Poor appetite or overeating
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6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
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7. Trouble concentrating on things, such as reading the newspaper or watching television
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8. Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
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9. Thoughts that you would be better off dead or of hurting yourself in some way
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10. If you checked off any problems, how difficult have these problems made it for you to work, take care of things at home, or get along with other people?
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Not at all difficult
Somewhat difficult
Very difficult
Extremely difficult
1. Feeling nervous, anxious, or on edge?
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2. Not being able to stop or control worrying?
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3. Worrying too much about different things
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4. Trouble relaxing?
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5. Being so restless that it is hard to sit still?
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6. Becoming easily annoyed or irritable?
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7. Feeling afraid as if something awful might happen?
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8. If you checked off any problems, how difficult have these problems made it for you to work, take care of things at home, or get along with other people?
Not at all difficult
Somewhat difficult
Very difficult
Extremely difficult
1. Interested
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2. Distressed
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3. Excited
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4. Upset
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5. Strong
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6. Guilty
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7. Scared
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8. Hostile
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9. Enthusiastic
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10. Proud
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11. Irritable
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12. Alert
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13. Ashamed
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14. Inspired
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15. Nervous
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16. Determined
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17 Attentive
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18. Jittery
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19. Active
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20. Afraid
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