K10 Form Name * First Name Last Name Email * Date MM DD YYYY 1. About how often did you feel tired out for no good reason? * None of the time A little of the time Some of the time Most of the time All of the time 2. About how often did you feel nervous? * None of the time A little of the time Some of the time Most of the time All of the time 3. About how often did you feel so nervous that nothing could calm you down? * None of the time A little of the time Some of the time Most of the time All of the time 4. About how often did you feel hopeless? * None of the time A little of the time Some of the time Most of the time All of the time 5. About how often did you feel restless or fidgety? * None of the time A little of the time Some of the time Most of the time All of the time 6. About how often did you feel so restless you could not sit still? * None of the time A little of the time Some of the time Most of the time All of the time 7. About how often did you feel depressed? * None of the time A little of the time Some of the time Most of the time All of the time 8. About how often did you feel that everything was an effort? * None of the time A little of the time Some of the time Most of the time All of the time 9. About how often did you feel so sad that nothing could cheer you up? * None of the time A little of the time Some of the time Most of the time All of the time 10. About how often did you feel worthless? * None of the time A little of the time Some of the time Most of the time All of the time 11. In the last four weeks, how many days were you totally unable to work, study or manage your day to day activities because of these feelings? (Type a number from 0 to 28) * 12. Aside from those days, in the last 4 weeks, how many days were you able to work or study or manage your day to day activities, but had to cut down on what you did because of these feelings? (Type a number from 0 to 28) * 13. In the last 4 weeks, how many times have you seen a doctor or any other health professional about these feelings? (Type the number of consultations) * In the last 4 weeks, how often have physical health problems been the main cause of these feelings? * None of the time A little of the time Some of the time Most of the time All of the time Thank you! *Indicates a required field