Rate yourself on the scale below. For each of the fifteen questions, choose a number from 0=5 that shows how you have felt during the last 3 months. 1. Do you get tired easy? Do you feel worn out? No Change 0 1 2 3 4 5 Much Change 2. Do you get upset when people tell you “You don’t look so good lately? No Change 0 1 2 3 4 5 Much Change 3. Are you working harder and harder and feel like you’re getting nothing done? No Change 0 1 2 3 4 5 Much Change 4. Are you more sarcastic and disappointed in the world around you? No Change 0 1 2 3 4 5 Much Change 5. Are you sad a lot and don’t know why? No Change 0 1 2 3 4 5 Much Change 6. Are you more forgetful (missing doctor visits, losing things)? No Change 0 1 2 3 4 5 Much Change 7. Are you grumpy? More short-tempered? Do you expect more and more from the people around you? No Change 0 1 2 3 4 5 Much Change 8. Are you spending less time with your friends and family? No Change 0 1 2 3 4 5 Much Change 9. Are you too busy to do every day things (make phone calls, send out cards)? No Change 0 1 2 3 4 5 Much Change Do you always feel bad or are you sick all the time? No Change 0 1 2 3 4 5 Much Change 10. Do you feel confused at the end of the day? No Change 0 1 2 3 4 5 Much Change 11. Do you have trouble feeling happy? No Change 0 1 2 3 4 5 Much Change 12. Are you unable to laugh at a joke about yourself? No Change 0 1 2 3 4 5 Much Change 13. Does sex seem like more trouble than it’s worth? No Change 0 1 2 3 4 5 Much Change 14. Do you have very little to say to people? No Change 0 1 2 3 4 5 Much Change Calculate Score: _ _ _ _ _ _ If your score is: Scores 0-25: Doing Fine Scores 26-35: Watch out, you are at risk. Scores 36-50: Candidate for Burnout. Scores 51-65: You are Burning out. Scores 65+: You are totally Burned out. Get help!