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Brief Mood Survey (After Session)
Please complete this form immediately *after* your session with Dr. Huberman, indicating how you feel *right now.*
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Your Name:
*
Your answer
Today's Date:
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MM
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YYYY
How depressed do you feel right now?
1. Sad or down in the dumps
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Not at all
0
1
2
3
4
Extremely
2. Discouraged or hopeless
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Not at all
0
1
2
3
4
Extremely
3. Low self-esteem, inferiority, or worthlessness
*
Not at all
0
1
2
3
4
Extremely
4. Loss of motivation to do things
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Not at all
0
1
2
3
4
Extremely
5. Loss of pleasure or satisfaction in life
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Not at all
0
1
2
3
4
Extremely
Suicidal urges: Right now
1. Do you feel like you'd be better off dead?
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Not at all
0
1
2
3
4
Extremely
2. Do you have suicidal thoughts or fantasies?
*
Not at all
0
1
2
3
4
Extremely
3. Do you have urges or plans to end your life?
*
Not at all
0
1
2
3
4
Extremely
How anxious do you feel right now?
1. Anxious
*
Not at all
0
1
2
3
4
Extremely
2. Frightened
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Not at all
0
1
2
3
4
Extremely
3. Worrying about things
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Not at all
0
1
2
3
4
Extremely
4. Tense or on edge
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Not at all
0
1
2
3
4
Extremely
5. Nervous
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Not at all
0
1
2
3
4
Extremely
How angry do you feel right now?
1. Frustrated
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Not at all
0
1
2
3
4
Extremely
2. Annoyed
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Not at all
0
1
2
3
4
Extremely
3. Resentful
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Not at all
0
1
2
3
4
Extremely
4. Angry
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Not at all
0
1
2
3
4
Extremely
5. Irritated
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Not at all
0
1
2
3
4
Extremely
Positive Feelings
How do you feel right now?
1. I feel happy and joyful.
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Not at all
0
1
2
3
4
Extremely
2. I feel hopeful and optimistic.
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Not at all
0
1
2
3
4
Extremely
3. I feel good about myself.
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Not at all
0
1
2
3
4
Extremely
4. I feel motivated and productive.
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Not at all
0
1
2
3
4
Extremely
5. I'm finding pleasure and satisfaction in life.
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Not at all
0
1
2
3
4
Extremely
How close do you feel to others right now?
1. I feel close and connected to others.
*
Not at all
0
1
2
3
4
Extremely
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