CONFIDENTIAL
Patient name
Ward no. Bed no.
Date
Word List
Please write a number from 1 to 5 by each of the words
listed on this sheet to indicate how you are feeling at the
present moment. Please refer to the scale below to select
the most appropriate number for each word, e.g. if you feel
moderately alert then you should write ‘3’ in the box
beside the word ‘alert’.
1
2
3
4
5
not at all
a little
moderately
quite a bit
extremely
active
afraid
alert
ashamed
attentive
distressed
determined
guilty
enthusiastic
hostile
excited
irritable
inspired
jittery
interested
nervous
proud
scared
strong
upset