1.	Difficulty sleeping	________
2.	Sleep too much	________
3.	Weight gain or loss (at least 10 lbs. in the last 2 weeks)	________
4.	Agitation or Irritability	________
5.	Difficulty concentrating	________
6.	Low interest in fun activities	________
7.	Lack of sex drive	________
8.	Feelings of hopelessness	________
9.	Thoughts of death	________
10.	Plan for suicide	________
11.	Substance abuse	________
12.	Separated, Divorced	________
13.	No Intimate Relationships	________
14.	Recent loss causing grief	_________