Please answer these questions as they relate to the past two weeks.

In the past two weeks how much have you been distressed by:

How have you been getting along in the following areas of your life over the past two weeks?

If you did not answer NEVER on #10 above,

The questions in this document are derived from the BHM-20® which is copyrighted work as listed below. No questions have been altered. The form was reformatted for ease of use. © By S. Mark Kopta and Jenny L. Lowry, 1997. All rights reserved.