Name: | Age: | ||||
Date of birth: (dd/mm/yyyy) | Sex: Male Female | ||||
Date form completed: (dd/mm/yyyy) | |||||
1. To what degree do each of the following change with the seasons? (Mark one square only per question.) | |||||
0 No change | 1 Slight change | 2 Moderate change | 3 Marked change | 4 Extremely marked change | |
A. Sleep length | |||||
B. Social activity (including family, friends, and coworkers) | |||||
C. Mood (overall feeling of well being) | |||||
D. Weight | |||||
E. Appetite | |||||
F. Energy level | |||||
Total score:__________ | |||||
2. If you experience changes with the seasons, do you feel that these are a problem for you? | |||||
No Yes | |||||
If yes, is the problem... | Mild | Moderate | Marked | Severe | Disabling |
3. Do you typically feel worst in Winter? | |||||
No Yes |
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